POIE 4033 SURGICAL INSTRUMENTATION AND EQUIPMENT TOURNIQUET SITI ZAIRINI AHMAD ILKKM KUBANG KERIAN
LEARNING OUTCOMES At the end of this learning session, the student will be able to • Explain the types of tourniquet • Discuss the precaution in using a pneumatic tourniquet • Describe the contraindication for tourniquet use • Demonstrate care and handling of tourniquet
DEFINITION • A tourniquet is a device used to provide hemostatic by constricting the flow of the blood in and extremity. • It is frequently used on the proximal aspect of an extremities to keep the distal surgical site free of blood. • A bloodless field makes dissection easier and less traumatic to tissue and reduces surgical times. • Bleeding must be controlled before the pressure is released.
INTRODUCTION • Many orthopedic operation a perform under tourniquet in a bloodless field. A correctly applied tourniquet with compress the vessel just sufficiently to stop blood flow and no more. • Excessive is not only unnecessary but carries with it the danger of irreversible ischemia in the muscle and damage to the nerve fibre.
TYPE OF TOURNIQUET There are two types of tourniquet : 1. Non pneumatic tourniquet (NONINFLATABLE) • Constructed of rubber or elasticized cloth 2. Pneumatic tourniquet • Which have cuffs that are inflated by compressed gas
NON PNEUMATIC TOURNIQUET • The surgical use of non pneumatic tourniquet is very limited • Historically, the use of a surgical glove as a wrist tourniquet for hand surgery • Principle of this tourniquet is it compress the superficial the blood vessel force blood out of the extremities.
NON PNEUMATIC TOURNIQUET The set contains : 1. BLOOD PRESSURE CUFF • The cuff is inflated with ambient air. • The surgeon determines the amount of pressure to be sustained. • The regulator valve is tightened. • The pressure gauge or sphygmomanometer must be monitored of pressure deviations.
NON PNEUMATIC TOURNIQUET 2. RUBBER BAND, TUBING/GLOVE This maybe used as a tourniquet of a finger or toe. The surgeon will put the sterile rubber band on the digit after draping.
NON PNEUMATIC TOURNIQUET 3. ESMARCH’S BANDAGE • Rubber tourniquet that is wrapped around the extremity • From distal to proximal before starting a surgical procedure to exsanguinate the limb before the inflation of proximally placed pneumatic tourniquet. • An Esmarch’s bandage is used to compress superficial vessels of blood out of an extremities.
ESMARCH’S BANDAGE
NON PNEUMATIC TOURNIQUET 4. RUBBER TUBING • When an IV infusion is started, a small length of rubber tubing is tied around the extremity, usually an arm, while the needle is inserted. • This stops venous return and makes the vein more visible for venipuncture. • A Penrose drain is commonly used as a tourniquet.
PNEUMATIC TOURNIQUET • Principle of this system is used blood pressure cuff has stronger features • Cuff is usually inflates automatically with compress air/nitrogen to maintained the pressure • Some new models inflate power by using battery unit • Desire pressure is maintain with register on pressure gauge mounted on portable stand or I/V pole
PNEUMATIC TOURNIQUET • Advance model is computerized control by microprocessor characterized with audible alarm, visual indicators for deviation from preset pressure and for elapsed time of inflation. • Should be user and maintain according manufacturer written instruction and easily available to the user
1. Cuff with difference sizes 2. Pressure source 3. Regulator device 4. Switch function for ON and OFF 5. Switch for setting Alarm Timer 6. Tubing and connectors COMPONENTS PNEUMATIC TOURNIQUET
CUFF WITH DIFFERENCE SIZES
PRESSURE SOURCE
REGULATOR DEVICE
TUBING AND CONNECTORS
PNEUMATIC TOURNIQUET • The calculation of tourniquet cuff pressure is according to the systolic blood pressure. An exact pressure to which the cuff should be inflated has not beep determined. • In a healthy adult, upper extremity pressure 30 to 70 mmHg higher than the systolic value of the blood pressure maybe sufficient to suppress arterial circulation. • Tourniquet pressure on an average adult arm usually range from 250 – 300mmHg (up to 6lb).
PNEUMATIC TOURNIQUET • In the lower extremity, cuff pressure should be higher than the systolic pressure by one half the value. This may require 350mmHg on the thigh. • Thin adult and children required less pressure; muscular and obese extremities may require more. • Inflation time should be kept to a minimum. If needed for more than 1 hour on an arm or 1 ½ hours on a leg, the tourniquet is deflated at intervals periodically at the discretion of the surgeon.
HOW TO CHOOSE THE CORRECT SIZE OF CUFF 1. Determined by patient’s age and anatomy 2. Length – when applied, it should overlap at least 3 inches (7.5 cm) but not more than 6 inches (15cm) 3. Width – not too wide because the flow of blood will be occluded a lower pressure therefore cause more damage.
The correct pressure will depend on : • Age of patients • Systolic blood pressure of the patient • Size of extremities HOW TO CHOOSE THE CORRECT PRESSURE
SIZE OF EXTREMITIES HEALTHY ADULT • Upper extremity pressure 30 – 70 mmHg higher than systolic value. Should not exceed 250 – 350 mmHg (upper arm) / 5-6 lbs per square inch. • Lower extremity – ½ the value of the systolic pressure. Should not exceed 500 mmHg/10 lbs per square inch. CHILD • Upper arm – 180 - 200 mmHg • Lower limb – 200 - 250 mmHg
PRECAUTIONS TO BE TAKEN WHEN USING A PNEUMATIC TOURNIQUET BEFORE 1. Check the tourniquet system • Inspect the inflatable cuff connector and tubing’s for cleanliness, integrity, and function. • Ensure the cuff in correct size and no leaking. • Ensure the cuff and tubing’s are intact and connectors are securely fastened to prevent disconnection during surgery. • Check the pressure gauge for accuracy
2. Protect patient’s skin under the tourniquet cuff. • Protect with wrinkle free pad such as orthoband • Make sure it is dry to prevent maceration or burn 3. Make sure the patient is well is anaesthetic and inform the anaesthesiologist. 4. Position the tourniquet at the point of maximum circumference of the limb. E.g above the elbow / knee joint because there is the place which is sufficient un muscle bulk and allow the pressure to be evenly spread.
5. Select cuff of appropriate width for size and shape of extremity. A proper cuff seal may result in bruising, blistering, pinching and necrosis of the skin. 6. Secure the tourniquet by tying the cuff string in bow. Cuff must not punctured with sharp instrument. E.g towel clip 7. Exsanguinate the extremity with esmarch band before cuff inflation(to compress the superficial veins) to prolong tourniquet time or elevate the extremity for 2-5 minutes to encourages venous return by gravity.
8. Inflated to the required pressure when surgeon is ready for operation (incision time) to reduced tourniquet time.
DURING 1. Ensure the cuff is not rotated to the a new position after application because it will lead to shearing force, which will be damage the underlying tissue. 2. Ensure the pressure gauge is clearly visible. Check the cuff periodically during the inflation for pressure fluctuation • Excessive pressure will cause nerve damage • Insufficient pressure will cause passive venous congestive of the part with hemorrhagic infiltration of the nerve
3. Record time tourniquet is applied – inflate and deflate 4. Informed the surgeon when the cuff is inflated for an hour and 15 minutes there after.
AFTER 1. Record time applied, inflate, deflated and removed 2. Remove the cuff and padding 3. Inspection – skin any sign of chemical burn. E.g brushing, blistering, pinching and necrosis 4. Massage the affected area to increase blood circulation
5. Documentation / record • Location of cuff and pressure setting • Time of inflating and deflating • Model and serial number of the tourniquet used • Assessment of skin condition and the tissue integrity preoperatively and evaluation after using the tourniquet. 6. Clean and dry all the equipment that are used 7. Test cuff, tubing, connector and gauge before storage.
8. Clean and inspect the pneumatic tourniquet after each patient use. • Wash the reusable cuff and bladder according to manufacturer instructions • Rinse and dry the cuff and bladder. • Wipe the connecting tubing with a disinfectant. • Test the cuff, tubing, connectors, and gauges before storage between uses.
CONTRAINDICATION Tourniquets are not used in the presence of 1. Infection or venous stasis in the limb 2. Malignant disease in the limb (may cause spread) 3. Vascular access ports or shunts (can destroy the patency of the structure) 4. Known peripheral vascular disease or history of DVT 5. Extremes of age: neonate or elderly 6. Rheumatoid arthritis 7. Skin grafts 8. Peripheral arteries disease e.g. Raynoud disease or Buerger’s syndrome CONTRAINDICATION
CONTRAINDICATION