Orthopaedics
Procedures under tourniquet
Livia Malanjum
Barrie Fischer
Abstract
The pneumatic tourniquet is used widely in operations involving the
limbs. However, despite its everyday use, a clinicians knowledge of this
instrument is often limited to the pressure and time limit. Although the
principle behind the tourniquet is simple, anaesthetists and surgeons
should appreciate the effects of the tourniquet as well as the various
complications associated with its use. Safe use of the tourniquet starts
from the point of setting up the pneumatic machine. It is important to
choose the appropriate pressure. Overinflation can lead to nerve dam-
age. On the other hand, underinflation will lead to a bloody surgical
field and unnecessary blood loss. The tourniquet should be applied with
care to avoid local damage to the skin. Pathophysiological effects of the
tourniquet can vary from a simple tachycardia and increase in systolic
pressure to fatal events such as large pulmonary embolus and cardiac ar-
rest. Prolonged use of the tourniquet can lead to a phenomenon known
as tourniquet pain. Other complications associated with the use of the
tourniquet include nerve and vascular damage and muscle contracture.
In the past, the use of the tourniquet was avoided in patients with sickle
cell disease for fear of triggering a sickle cell crisis. However, it has been
shown that by creating the optimum conditions sufficient hydration,
good oxygenation, warmth and mild hyperventilation this group of
patients should not be deprived of the choice of having their limb opera-
tions with a tourniquet.
Keywords machine check; nerve damage; pathophysiology; pneumatic
tourniquet; pulmonary embolus; sickle cell disease
The use of a tourniquet in operative procedures dates back to
Roman times. However, it was specifically used in limb ampu-
tations. In 1864, Lister became the first surgeon to apply the
concept of the bloodless surgical field in operations other than
amputations. The tourniquet is applied around the upper and
lower extremities to reduce blood loss and create good operating
conditions. In 1904, Harvey Cushing introduced the pneumatic
Livia Malanjum, MBChB, is a Specialty Registrar in Anaesthesia and
Critical Care Medicine and is currently working at Leicester General
Hospital, Leicester, UK. She qualified from the University of Bristol.
Conflicts of interest: none declared.
Barrie Fischer, FRCA, is Consultant Anaesthetist at the Worcestershire
Acute Hospitals Trust (Alexandra Hospital, Redditch). He qualified from
Bristol University and trained in Cornwall, Cambridge and Cardiff. His
research and teaching interests are the role of regional anaesthesia in
surgery and acute pain medicine. Conflicts of interest: none declared.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 10:1
tourniquet for use in limb surgery in place of rubber tourniquets.
One hundred years on, it is still considered an essential tool in
orthopaedic and plastic surgery. However, the use of the tourni-
quet is not without its risks and complications.
Applying the tourniquet
The diameter of the cuff used should be wider than half the
diameter of the limb. It should be applied furthest away from the
surgical site and preferably over an area with the most fat and
muscle padding. The edges of the cuff must overlap to provide
even pressure all around. The use of soft-cast padding under-
neath the cuff is advised. When using padding, there should be
no creases or ridges as this is associated with significant skin
irritation and blistering. When the skin is prepared prior to sur-
gery, the organic iodine or alcohol solution can become soaked
up by the padding and can cause chemical burns and blistering.
To prevent this from happening, an adhesive, transparent surgi-
cal barrier can be used to isolate the tourniquet and its padding
(Figure 1).
Exsanguinating the limb
There are two ways to exsanguinate the limb:
1 Passive method: achieved by elevating the arm or leg for
5 minutes at 90 and 45, respectively, without mechanical
compression.
2 Active method: by using the Esmarch bandage or a Rhys-
Davies exsanguinator (Figure 2). This method is contraindi-
cated in patients with infection, tumour or painful fractures.
Inflation pressures and time limit
To achieve complete arterial occlusion, inflation pressures should
be related to a patients systolic blood pressure (Figure 3):
Inflation pressures for lower limbs: at least 100 mm Hg above
systolic arterial blood pressure (usually 300500 mm Hg).
Inflation pressures for upper limbs: at least 50 mm Hg above
systolic arterial blood pressure (usually 250300 mm Hg).
In order to minimize the risk of nerve damage, the lowest
inflation pressure should be used.1 In normotensive patients with
compliant vessels, lower inflation pressures would be sufficient
Figure 1 Tourniquet cuff, soft padding and Esmarch bandage.
14 2008 Elsevier Ltd. All rights reserved.
 Orthopaedics
Figure 2 The Rhys-Davies exsanguinator.
to occlude arterial flow. In contrast, morbidly obese and hyper-
tensive patients would require much higher inflation pressures.
Recommendations and advice on the time limit for the use of
the tourniquet varies from 30 minutes to 4 hours, with 2 hours
being the most widely accepted figure. The risk of muscular and
neurological damage increases with prolonged ischaemia. Unfor-
tunately, in complicated operations, the actual procedure may
take longer than 2 hours. In such situations, ideally the tourni-
quet should be deflated after 2 hours for 1520 minutes to allow
reperfusion of the muscle beneath and distal to the tourniquet
cuff. After this period of reperfusion, the tourniquet should be
used for only a further 60 minutes.2
The contraindications to the use of a tourniquet are shown
in Table 1.
Effects of the tourniquet
The pathophysiological changes related to the use of the tourni-
quet can be divided into two phases: during inflation and after
deflation.
During inflation
Cardiovascular effects:
Increase in circulating blood volume (up to 15%) and systemic
vascular resistance (up to 20%), leading to a transient slight-to-
Figure 3 Tourniquet inflation unit.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 10:1
Contraindications to the use of a tourniquet
Absolute contraindications
Presence of arteriovenous fistula
Peripheral vascular disease
Active malignancy
History of vascular surgery in the involved limbs
Relative contraindication
Sickle cell disease
History of deep vein thrombosis, thromboembolic disease or
pulmonary embolus
Obese thigh
Multiply scarred legs
Diabetes
Rheumatoid arthritis
Revision surgery
Table 1
moderate increase in central venous pressure and systolic blood
pressure.3 If bilateral simultaneous inflation of a lower limb
tourniquet is carried out, the rise in central venous pressure may
be significant enough to cause volume overload or even cardiac
arrest.
A sudden marked rise in heart rate and systolic and diastolic
blood pressures may occur after 3060 minutes. This phenome-
non in also known as tourniquet pain. Increasing the depth of an-
aesthesia and the use of opiates may not be able to reverse these
changes. It will improve only once the tourniquet is deflated.
The mechanism of tourniquet pain is poorly understood. It is
more likely to occur with increasing age and increasing duration
of surgery.
Temperature effect:
Increase in core body temperature due to reduction in surface
area for heat loss.
Decrease in temperature of the non-perfused limb. This may
provide some protective effect from ischaemic changes.
Haematological effects:
Systemic hypercoagulability may occur in response to tourni-
quet and surgical pain. Platelet aggregation is promoted by cat-
echolamine release.
Pulmonary embolus has been associated with the use of a
tourniquet and there are case reports in which these incidents
have been fatal. It can occur during lower limb exsanguinations
and tourniquet inflation as well as during tourniquet deflation.
There is a 5.33-fold increased risk of large venous embolism as-
sociated with the use of a tourniquet in patients undergoing total
knee arthroplasty.4
The incidence of deep vein thrombosis associated with the
use of a tourniquet and total knee replacements is reported to be
between 50% and 84%.5
Metabolic effects:
After 30 minutes, anaerobic metabolism occurs. This leads to
mixed acidosis, hypoxaemia, hypercapnia, hyperkalaemia and
15 2008 Elsevier Ltd. All rights reserved.
 Orthopaedics

formation of free radicals. These changes may be slight, but they
may be of consequence in those with limited cardiopulmonary re-
serve.
After deflation
Cardiovascular effect:
During limb reperfusion, a transient decrease in systemic
vascular resistance accompanied by a compensatory increase in
cardiac index may occur. This avoids a severe decrease in mean
arterial pressure.
Reactive hyper-reperfusion and vasospasm.
Temperature effect:
As blood returns to cold ischaemic tissues, the core tempera-
ture may fall by up to 0.6C for each hour the tourniquet was
used.
by stiffness, pallor, weakness without paralysis and subjective
numbness of the extremity without subjective anaesthesia.
Sickle cell disease
The use of tourniquets in patients with sickle cell disease remains
a subject of debate. Low oxygen concentration in the ischaemic
limb, circulatory stasis and acidosis may precipitate a sickle cell
crisis. Traditionally, tourniquets were avoided in patients with
sickle cell disease. However, Gyamfi et al.6 reported the success-
ful use of tourniquets in patients with sickle cell disease both
those who are heterozygous and those who are homozygous
for the disease. Precautions must be taken to optimize condi-
tions adequate hydration, warmth and blood volume as well as
maintaining oxygenation and mild hyperventilation in order to
reduce the risk of precipitating a sickle cell crisis.

Respiratory effects:
Machine check
There may be a transient increase in end-tidal carbon dioxide
tension by 0.12.4 kPa that peaks within 1 minute and returns to Equipment failure may contribute to the range of complications
baseline within 1013 minutes. that can result from the use of tourniquets. This may be from
There may be increased oxygen consumption. overpressurization or underpressurization, adding to the com-
plications related to the use of tourniquets. Therefore, all tourni-
Metabolic effects: quets should undergo regular maintenance checks to determine
Increase in lactate and Paco2. reliability (Table 3).
Decrease in pH.
Increase in plasma K+ level.
Ischaemic preconditioning
The complications associated with the use of tourniquets are
shown in Table 2. The concept of ischaemic preconditioning has been described
in the protection of cardiac muscles in cardiac surgery. Expos-
ing cardiac tissues to short periods of non-damaging ischaemic
Post-tourniquet syndrome
stress prior to the main ischaemic phase produces an adaptive
This is the most common morbidity from tourniquet use but is protective response. Ischaemic preconditioning can lead to the
the least appreciated. It is the result of muscle ischaemia, oedema production of protective substances such as adenosine, brady-
and microvascular congestion. The syndrome is characterized kinin and nitric oxide. Adenosine has been particularly identi-
fied as it prevents leucocyte sequestration, increases the activity
of antioxidant enzymes and preserves ATP levels.7 However,
although the protective role of ischaemic preconditioning has
Complications associated with the use of tourniquets
been studied in animal skeletal muscles, to date no human stud-
ies have been conducted. If it is proven that preconditioning
Local effects
can benefit human skeletal muscles, then the principle can be
Skin damage, bruising
applied to reduce the various complications involved with the
Neuralgia, paraesthesia
use of tourniquets.
Vascular damage: thrombosis to atherosclerotic vessels
Muscle contracture
Prolonged oedema and stiffness
Safety check
Bone and soft-tissue necrosis
Compartment syndrome
Visual inspection of the machine: rubber tubing, connections
Delayed wound healing
and cuff
Systemic effects Check accuracy of aneroid pressure gauges against a suitable
Pulmonary embolus calibration device
Pulmonary oedema When inflating the cuff, monitor the pressure gauge to ensure
Transient increase in blood pressure it achieves the pre-set inflation pressure
Tourniquet pain Monitor the pressure gauge intermittently throughout the
Post-tourniquet syndrome procedure to detect any changes and exclude any leaks
Tourniquet-induced rhabdomyolysis The anaesthetic record should include the position of the
Cardiac arrest cuff, pressure used and time

Table 2 Table 3

ANAESTHESIA AND INTENSIVE CARE MEDICINE 10:1 16 2008 Elsevier Ltd. All rights reserved.
 Orthopaedics
Other techniques that have been used in place of
tourniquets or in combination with tourniquets
Hypotensive epidural anaesthesia in total knee replacements
without use of tourniquets
Adrenaline and local anaesthetic infiltration in total knee
replacements
Controlled hypotension and minimal inflation pressure in
upper limb surgery
Table 4
Future of tourniquets in orthopaedic surgery
There have been questions as to whether tourniquets are abso-
lutely indispensable in limb surgery. The concern is that, without
using a tourniquet, blood loss would be significant. It will not
only increase the need for transfusion but, as the surgical field
would be greatly obscured, the operation would take longer than
necessary. Nevertheless, this is not completely true in all limb
surgeries. Wakankar et al.8 compared the outcome for total knee
replacements with and without the use of tourniquets. The study
showed that there was no significant difference in the surgical
time, postoperative pain, need for analgesia, the volume col-
lected in the drains, postoperative swelling and the incidence of
wound complications. If the outcome is similar, should surgeons
be considering performing total knee replacements without tour-
niquets? It is indeed an issue of balancing the risks and benefits
as well as the skills of the surgeon performing the operation.
Other techniques that have been used in place of tourniquets
are shown in Table 4. 44-B: 93743.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 10:1
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Further reading
Anaesthesia UK. Procedures under tourniquet. Available from:
www.frca.co.uk
Kam PCA, Kavanaugh R, Yoong FFY. The arterial tourniquet:
pathophysiological consequences and anaesthetic implications.
Anaesthesia 2001; 56: 53445.
Klenerman L. The tourniquet in surgery. J Bone Joint Surg Br 1962;
17 2008 Elsevier Ltd. All rights reserved.