Use of a Tourniquet in the Operating Room

Tourniquet in the Operating Room

The tourniquet is a commonly used device in the operating room (OR), particularly in orthopedic and vascular surgeries involving the limbs. Its primary function is to reduce the amount of blood in the surgical field by temporarily restricting arterial blood flow to the operative site. While the use of a tourniquet can enhance surgical precision and reduce blood loss, it also introduces specific physiological effects and potential complications that must be carefully managed by the surgical and anesthesia teams.

A surgical tourniquet is typically applied to the upper arm or thigh in the OR and inflated to a pressure sufficient to occlude arterial inflow. This controlled ischemia minimizes intraoperative bleeding and improves visibility for the surgeon. Tourniquets are most often used in procedures involving distal limb structures, such as carpal tunnel release, total knee arthroplasty, fracture fixation, and tendon repairs 1–6.

One of the main advantages of tourniquet application is the creation of a bloodless field, which allows for more accurate dissection, quicker identification of anatomic structures, and reduced operative time in some cases. Additionally, by reducing blood loss during surgery, tourniquet use may lower the need for intraoperative transfusions, especially in limb surgeries 7.

However, tourniquet inflation causes ischemia in the distal limb, and its release can lead to significant physiological changes. Ischemia leads to anaerobic metabolism, resulting in the accumulation of lactic acid and other metabolites. When the tourniquet is deflated, these byproducts are rapidly released into the systemic circulation, potentially causing transient hypotension, acidosis, and hyperkalemia. For this reason, the anesthesiologist must closely monitor hemodynamic status during and after tourniquet deflation 8,9.

The duration of continuous tourniquet inflation is a key safety consideration. Prolonged use, typically beyond 2 hours, increases the risk of nerve injury, muscle damage, and reperfusion complications. Most guidelines for tourniquet use in the OR recommend deflating the tourniquet for at least 15 minutes after prolonged use to allow for reperfusion before reapplication if further ischemia is needed 8,10.

Although tourniquets are generally safe when used appropriately, complications can occur. These include but are not limited to nerve palsy, postoperative swelling, compartment syndrome, and delayed wound healing. Contraindications to tourniquet use include sickle cell disease, severe peripheral vascular disease, and certain coagulation disorders, where ischemia or pressure could exacerbate underlying pathology 7,8,11.

The tourniquet remains a valuable tool in the OR, particularly for limb surgeries requiring precise visualization and minimal bleeding. However, its use must be balanced with a clear understanding of its physiological effects, potential complications, and appropriate timing. Close coordination between the surgical and anesthesia teams, as well as adherence to established protocols, is essential for maximizing the benefits of tourniquet use while minimizing associated risks.

 

References

  1. Welling, D. R., McKay, P. L., Rasmussen, T. E. & Rich, N. M. A brief history of the tourniquet. Journal of Vascular Surgery 55, 286–290 (2012). DOI: 10.1016/j.jvs.2011.10.085
  2. Stopping bleeding with a tourniquet: MedlinePlus Medical Encyclopedia Image. https://medlineplus.gov/ency/imagepages/1068.htm.
  3. Ishii, Y., Noguchi, H. & Takeda, M. Clinical use of a new tourniquet system for foot and ankle surgery. Int Orthop 34, 355–359 (2010). DOI: 10.1007/s00264-009-0804-3
  4. Davey, M. S., Davey, M. G., Hurley, E. T. & Kearns, S. R. Tourniquet Use During Open Reduction and Internal Fixation of Ankle Fractures – A Systematic Review and Meta-Analysis. J Foot Ankle Surg 61, 1103–1108 (2022). DOI: 10.1053/j.jfas.2022.01.019
  5. Sasor, S. E. et al. Tourniquet Use in Wide-Awake Carpal Tunnel Release. Hand (N Y) 15, 59–63 (2020). DOI: 10.1177/1558944718787853
  6. Ahmed, I. et al. Tourniquet use for knee replacement surgery. Cochrane Database Syst Rev 2020, CD012874 (2020). DOI: 10.1002/14651858.CD012874.pub2
  7. Khan, A. L. & Gray, A. Tourniquet uses and precautions. Surgery (Oxford) 32, 131–133 (2014).
  8. Sharma, J. P. & Salhotra, R. Tourniquets in orthopedic surgery. Indian J Orthop 46, 377–383 (2012). DOI: 10.4103/0019-5413.98824
  9. BOA. BOAST – The Safe Use of Intraoperative Tourniquets. https://www.boa.ac.uk/resource/boast-the-safe-use-of-intraoperative-tourniquets.html.
  10. Safety Considerations During Use. tourniquets.org https://tourniquets.org/safety-considerations-during-use/.
  11. Mechanisms and Prevention of Injuries. tourniquets.org https://tourniquets.org/tourniquet-injuries-mechanisms-and-prevention/.