Trainee
Tourniquet safety – case report and national survey: Tourniquets in Orthopaedic Practice Study (TOPS) Caesar Wek, Alice Wales, Jonathan C Compson and Ines LH Reichert
A
recent complication directly attributed to the use of a tourniquet at our institution has highlighted the significant level of harm that a chemical burn may cause to the patient. This incident prompted a review of tourniquet practice, in particular to aspects of safety and teaching.
Caesar Wek is an ST8 Orthopaedic Registrar in London, on the South East Thames Training Rotation.
Tourniquets are frequently used during extremity surgery in trauma and orthopaedic surgery to provide a bloodless field. However, tourniquet use is not without its risks and complications range from mild skin irritation to a slow-healing chemical burn as well as temporary paraesthesia to nerve damage and paralysis1,2. The historical use of tourniquets dates back to the ancient Romans (199 BCE – 500CE) who used non-pneumatic bronze and leather devices to control bleeding when performing amputations on the battlefield3. The actual term ‘tourniquet’ was coined in the 1700s by Jean Louis Petit, a derivation of the French term tourner (‘to turn’)4. His simple device was a screw-like mechanism (see Figure 1) that was revolutionary in providing a constant pressure without the use of an assistant.
Alice Wales is the mother of the patient. She holds an MA (Nat Sci) from Cambridge University and is a Chartered UK and European Patent Attorney at Abel & Imray, specialising in life sciences and medical devices and methods.
48 | JTO | Volume 09 | Issue 03 | September 2021 | boa.ac.uk
Following the advent of general anaesthesia, Joseph Lister performed the first non-amputation surgeries with a tourniquet in 1864, using this device to create a bloodless surgical field5. Later, Friedrich von Esmarch created the flat rubber bandage that now bears his name and in the early 1900s, Harvey Cushing developed the pneumatic tourniquet, a variant of which is still used today3.
Figure 1: Petit tourniquet engraving from 1798.
This original design was further modified in the 1980s by James McEwen, who invented the modern microcomputer tourniquet. This top-of-the-range tourniquet device not only monitors tourniquet pressure but also leakage, inflation time, and various other parameters such as the Limb Occlusion Pressure (LOP)6. The technique of tourniquet application varies amongst surgeons and at present there is a paucity of guidance for tourniquet use in the United Kingdom. Furthermore, the use of tourniquets may give rise to complications and preventable damage due to over-pressurisation, insufficient sealing, and prolonged application. The aim of this study was to 1) establish current training and practice in the UK and 2) to estimate the incidence of post-tourniquet complications.
Our case report An eleven-year old girl required extensive release of her elbow joint including removal of heterotopic ossification and metal work a year following a complex elbow injury and fixation. She was operated on in October 2019 as a joint procedure by two upper limb consultants. She was placed in a lateral position and a high upper arm paediatric-sized tourniquet was applied with standard wool padding and occlusive tape. Standard surgical prep, alcoholic-based povidone iodine followed by alcoholic chlorhexidine was used and the upper arm was dried before surgical drapes were applied. The tourniquet time was recorded as 2 hours 6 minutes at a standard pressure setting for upper limb or slightly below, adjusted to blood pressure, but not clearly documented as such. No visible sign of injury was recorded in the notes immediately following removal of the tourniquet. The first sign of injury was noted on the following day when a painful purple area of inflammation was observed on the inside of her upper limb. This was initially considered to be pressure damage only, but developed rapidly over the following days into a sore approximately 7 x 6cm in size with superficial skin loss and de-roofed serous blisters. The paediatric tissue viability nurse was involved on one occasion and provided dressings but no ongoing treatment. After discharge from hospital, the wound deteriorated further
