Tourniquet safety – case report and national survey: Tourniquets in Orthopaedic Practice Study (TOPS)

Caesar Wek, Alice Wales, Jonathan C Compson and Ines LH Reichert

Caesar Wek is an ST8 Orthopaedic Registrar in London, on the South East Thames Training Rotation.

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.

Jonathan Compson is an Upper Limb Surgeon (elbow, wrist and hand) at Kings College Hospital, London. He has 25 years of tertiary referral practice and treating complex trauma. He is a previous council member of BSSH.

Ines Reichert is a Consultant Trauma & Orthopaedic Surgeon at King’s College Hospital London with an interest in Trauma, Upper Limb (hand/ wrist) and Diabetic Foot. She has completed a PhD at Imperial College and has maintained an active involvement in research - clinical and basic science. She serves presently as Treasurer on the Executive Board of the British Orthopaedic Research Society.

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.

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 paralysis[1,2].

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.

Figure 1: Petit tourniquet engraving from 1798

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 today[3].

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 to deep full thickness skin loss. Two courses of Flucloxacillin were prescribed for S.aureus infection of the wound. The soreness and pain of the wound complicated post-operative mobilisation significantly and the wound took in total around 6-8 months to heal. Treatment of a residual scar is ongoing.

A questionnaire was constructed based on current practice and available standards from the Association of Surgical Technologists (AST, United States of America) for recommended practice of tourniquet application[7]. The survey was distributed primarily but not exclusively to orthopaedic trainees nationally with the support of the British Orthopaedic Trainees Association (BOTA). The key aspects that the survey aimed to assess amongst the survey respondents were:

• Pre-operative tourniquet consent and WHO checklist

• Tourniquet application and technique

• Tourniquet type and padding

• Tourniquet seal and skin prep solutions

• Limb exsanguination and inflation pressure

• Tourniquet complications

• Tourniquet teaching and training

The questionnaire was in the form of 26 shortanswer questions using the online platform Google forms (Google LLC, California, USA), see appendix.

Learning points

Examples of the wound at the inner aspect of the upper arm caused predominantly by the chemical burn related to the tourniquet are shown at four time points (Figure 2a – d). The incident highlighted a number of shortcomings:

1. Requirement for consistent standard recording of tourniquet time and pressure.

2. Differentiated selection of tourniquet pressure taking site (upper / lower limb), blood pressure and age (adult / paediatric) into account.

3. Consider informed consent of a tourniquet complication.

4. Establish pathway for post-tourniquet identification of an adverse event, e.g. early recognition and documentation of any injury to skin, but also awareness of wool padding/ any sign of leakage of prep solution and establish pathways of treatment when a complication has been identified.

5. Emphasis and inclusion of teaching on rationale / risks and benefits of tourniquet application to increase awareness of pre-, intra- and post-operative complications.

These shortcomings are both individual and institutional, and have been addressed in a national survey directed predominantly to trainees.

Figure 2a: Tourniquet related wound caused by a chemical burn at the inside of the upper arm in an 11-year-old girl, day 9.

Figure 2b: Tourniquet related wound day 23.

Figure 2c: Tourniquet related wound day 94.

Figure 2d: Tourniquet related scar day 601.

Figure 3: Breakdown of respondents.

National survey

A total of 118 completed questionnaires were collected for analysis. The respondents were comprised of 81.1% of ST3-ST8 Trainees, 10.3% Consultants, 2.6% Senior Clinical Fellows, and 6% Trust Specialist Registrars (see Figure 2). The majority of respondents were from England with 35.9% based in a District General Hospital (DGH) and 23.9% based at a Major Trauma Centre (MTC).

Pre-operative tourniquet consent and WHO checklist

82.9% of respondents reported that they did not include tourniquet use and/ or tourniquet-related complications in their consent for procedures. 17.8-22.2% of respondents indicated they believed a check of the tourniquet site was included at some stage in the WHO checklist but 48.7% of the respondents were clear that there was no inclusion in the WHO checklist.

Tourniquet application and responsibility

83.8% of respondents indicated that the trainee predominantly applies the tourniquet cuff, with 88% of respondents stating that they understand the orthopaedic consultant has ultimate responsibility for final tourniquet position.

Tourniquet type and padding

48.7% of respondents reported that they used a sterile tourniquet for certain cases with arthroplasty being the most frequent, followed by sarcoma resection and combined orthoplastic cases. All respondents surveyed used padding with tourniquets, with wool padding used in 92.3% of cases and 24.8% used stockinette as an adjunct.

Tourniquet seal and skin prep solutions

A U-drape was used as seal by 71.8% of respondents, with a plastic occlusive sleeve used by 38.5% and sleek tape used as by 22.2%. 60% of respondents used specialist tourniquets in high BMI individuals. In elective surgery, 89.6% of those surveyed used alcoholic chlorhexidine for skin prep with 30.4% using aqueous chlorhexidine. 48.7% of respondents used alcoholic-based povidone iodine with 36.5% using aqueous povidone iodine.

Limb exsanguination and inflation pressure

For upper limb surgery, 76.9% of individuals used elevation alone, with 43.6% using a crepe bandage as an adjunct and 31.6% using the Rhys-Davies exsanguinator. In lower limb surgery, 76.1% of individuals used elevation alone, with 18.8% using a crepe bandage as an adjunct and 33.3% using the Rhys-Davies exsanguinator. Most respondents consider limb site (80.3%) and patient blood pressure (82.1%) when setting the tourniquet pressure. The respondents considered patient age in 30.8% of cases and limb size in 26.5% of cases. The Limb Occlusion Pressure (LOP) was considered a major factor by only 8.5% of respondents. The most commonly used inflation pressure in paediatric upper limb cases was 200 mmHg or less (32.5%), however 16.2% of respondents used pressures of 201-250 mmHg. In adult upper limb cases, the most used pressure was 201-250 mmHg (73.5%), with 15.4% of respondents using 250-300 mmHg.

Tourniquet complications

37.1% of respondents reported observing a tourniquet-related complication (see Figure 4). The most common complications reported were: post-operative tourniquet pain (69.6%), contusion (43%), nerve-related injuries (24.1%), chemical burns (13.9%) and pressure sores (6.3%).

Figure 4: Tourniquet-related complications.

Tourniquet training

Of the 118 respondents, 105 (89.7%) reported having never received any formal training in tourniquet applications. 6% received training in tourniquet application and only 1.7% received training in tourniquet safety. 4.3% were unsure if this had been provided.

Recommendations

The tourniquet is routinely used in operating theatres with various designs used in more than 15,000 procedures every day[3]. When utilised correctly, the limb tourniquet is a safe and an invaluable tool for the surgeon and anaesthetist which helps improve patient outcome by reducing blood loss and operating time[4]. Most tourniquet related complications are preventable. However, when these do occur they have a significant impact on patient outcomes and may have medicolegal implications[8].

Furthermore, as seen in the case reported herein, a tourniquet complication may impair patient rehabilitation, cause significant distress and prolong recovery with longer term and potentially permanent physical and psychological implications for the patient.

The results from our survey indicated that 89.7% of respondents received no formal training in tourniquet application and safety. A variety of methods were used to determine tourniquet application regarding padding, seal, and pressure. 82.9% of respondents did not routinely record tourniquet-related complications in the consent form. 48.7% of respondents reported that tourniquets were not included in the WHO checklist and there was little clarity as to who would be responsible for checking and documenting the tourniquet site post-surgery. Our results also indicated that tourniquet inflation pressures are often pre-selected using set pressures not necessarily individualised to limb size or systolic blood pressure. In paediatric cases, it is recommended that tourniquet pressures are 50 mmHg above systolic9. In adults, a tourniquet pressure of systolic blood pressure plus 70-130 mmHg for the lower limb and 50-100 mmHg for the upper limb[10] .

Approximately 37.1% of respondents have experienced tourniquet-related complications. These varied from post-operative tourniquet pain and contusion to more serious chemical burns and nerve-related injuries. These injuries may be preventable with careful tourniquet practice. The number of individuals reporting tourniquet-related complications was higher than the 10% reported by Sadri et al. (2010)[11]. The survey is a voluntary snapshot across trainees and captured responses from about a third of trainees. There might have been reporting bias as trainees with first-hand experience of tourniquet problems might have been more inclined to take part in the survey. Furthermore, the questions were frequently constructed to allow several answers, e.g. ‘all that apply’ and percentage numbers will need to be interpreted accordingly.

Importantly, it should be noted that only 1.6% of respondents reported receiving training in safe tourniquet practice. This is remarkable as tourniquet application is routine in orthopaedic and trauma surgery. The apprenticeship model of training has failed to include theoretical teaching on risks and safety of tourniquet application and use. We feel that in addition to the development of national guidelines for optimising tourniquet cuff pressure and technique, trainees should receive formal training in safe tourniquet practice and application and education as to the risks, identification and handling of tourniquet complications.

Editor Note: The BOA Orthopaedic Committee is also making final preparations on a new BOAST ‘The Safe Use of Intraoperative Tourniquets’, which will be published in September.

References and appendix

References and Appendix 1 can be found online at: www.boa.ac.uk/publications/JTO.