The Tourniquet Manual: Principles and Practice Leslie Klenerman Springer www.anaesthesia-database.blogspot.com The Tourniquet Manual – Principles and Practice Springer London Berlin Heidelberg New York Hong Kong Milan Paris Tokyo 1111 2 3 4 5 611 7 8 9 1011 11 2 3111 4 5 6 7 8 9 2011 1 1 2 3 4 5 6 7 8 9 3011 1 1 2 3 4 5 6 7 8 9 4011 1 211 Leslie Klenerman The Tourniquet Manual – Principles and Practice Leslie Klenerman, MBBCh, ChM, FRCSEd, FRCSEng Emeritus Professor of Orthopaedic and Accident Surgery, University of Liverpool, Liverpool, UK British Library Cataloguing in Publication Data Klenerman, Leslie The tourniquet manual : principles and practice 1. Tourniquets I. Title 617.9′178 ISBN 1852337060 Library of Congress Cataloging-in-Publication Data Klenerman, Leslie. The tourniquet manual : principles and practice/Leslie Klenerman. p. ; cm. Includes bibliographical references and index. ISBN 1-85233-706-0 (alk. paper) 1. Tourniquets–Handbooks, manuals, etc. I. Title. [DNLM: 1. Hemostatic Techniques. 2. Tourniquets. 3. Extremities–surgery. 4. Intraoperative Complications–prevention & control. 5. Orthopedic Procedures–methods. 6. Postoperative Complications–prevention & control. 7. Tourniquets–adverse effects. WH 310 K644t 2003] RD73.T6K54 2003 617′.9–dc21 2003045601 Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced, stored or transmitted, in any form or by any means, with the prior permission in writing of the publishers, or in the case of reprographic reproduction in accordance with the terms of licences issued by the Copyright Licensing Agency. Enquiries concerning reproduction outside those terms should be sent to the publishers. ISBN 1-85233-706-0 Springer-Verlag London Berlin Heidelberg a member of BertelsmannSpringer Science+Business Media GmbH http://www.springer.co.uk © Springer-Verlag London Limited 2003 The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore free for general use. Product liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. Typeset by Florence Production, Stoodleigh, Devon, England Printed in the United States of America 28/3830-543210 Printed on acid-free paper SPIN 10896266 1111 2 3 4 5 611 7 8 9 1011 11 2 3111 4 5 6 7 8 9 2011 1 1 2 3 4 5 6 7 8 9 3011 1 1 2 3 4 5 6 7 8 9 4011 1 211 This book could not have been started without the generous sponsorship of the Medical Defence Union, the Medical Protection Society, the British Association for Surgery of the Knee, the British Orthopaedic Foot Surgery Society, and Anetic Aid, a manufacturer of tourniquets. I am very grateful to these bodies for their help in making this book possible. Thanks are also due to my wife Naomi and my son Paul for their constant help, criticism and encouragement; to Professor Malcolm Jackson of the Department of Medicine, University of Liverpool, for help with biochemistry; to Derek Eastwood, John Kirkup and Durai Nayagam for their useful comments and correc- tions; to Alun Jones and Andrew Biggs in the Photographic Department at the Robert Jones and Agnes Hunt Hospital, Oswestry, for invaluable help with the illustrations; and to Stephen White for allowing me access to the theatre during his operation list. Acknowledgements v Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix 1 Historical Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.1 Screw Tourniquet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.2 Listerian Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 1.3 Esmarch’s Bandage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 1.4 The Pneumatic Tourniquet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 2 Effect of a Tourniquet on the Limb and the Systemic Circulation . . . . . 13 2.1 Application of the Tourniquet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 2.2 Sites of Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 2.3 Effect on Muscle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 2.4 Compression of Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 2.5 Effects on the Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 2.6 Systemic and Local Effects of the Application of a Tourniquet . . . . . . . 29 2.7 Haemodynamic Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 2.8 Limb Blood Flow in the Presence of a Tourniquet . . . . . . . . . . . . . . . . . 34 2.9 Hyperaemia and Swelling of a Limb After Release of a Tourniquet . . . . 35 2.10 Haematological Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 2.11 Temperature Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 2.12 Tourniquet Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 3 Ischaemia–Reperfusion Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 3.1 Metabolic Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 3.2 Reperfusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 3.3 Modifying Ischaemia–Reperfusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 4 Exsanguination of the Limb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 4.1 External Compression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 4.2 Sickle Cell Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 5 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 5.1 Damage to Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 5.2 Damage to Muscle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 5.3 Vascular Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 vii Contents 5.4 Damage to Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 5.5 Post-tourniquet Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 5.6 Potential of Cross-infection During Peripheral Venous Access by Contamination of Tourniquets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 6 The Tourniquet Used for Anaesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . 77 6.1 Intravenous Regional Anaesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 6.2 Digital Tourniquets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 6.3 Regional Sympathetic Blockade . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 7 Technology and Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 7.1 Design of the Tourniquet Cuff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 7.2 Hand-powered Tourniquets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 7.3 Automatic Tourniquets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 7.4 Safety Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 7.5 Practical Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 7.6 Golden Rules for the Safe Use of Tourniquets . . . . . . . . . . . . . . . . . . . . 99 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 viii Contents ➀➁➂➃➄➅➆ Why write a book on the tourniquet? The tourniquet is used routinely in oper- ating theatres throughout the world, but as far as I know there is no single book that surveys the considerable literature that has accumulated. If used sensibly, the tourniquet is a safe instrument. Most of the few complications seen with its use are preventable. However, when something untoward happens, the tourni- quet suddenly becomes an interesting subject, particularly if there is the likelihood of medicolegal consequences. This book summarises the scientific background of the tourniquet and describes a safe physiological approach to preventing complications. Examples of medicolegal problems are included. Considerable progress had been made since Lister first excised a tuberculous wrist joint in a bloodless field. Many researchers have studied the effects of ischaemia and pressure on nerves and muscles. Tourniquets have entered the age of computers and are now much more sophisticated. Despite this, there is still much dogma surrounding the tourniquet in operating theatres and in textbooks. This book is aimed at orthopaedic surgeons, anaesthetists and oper- ating-theatre staff. I hope that this short text will stimulate a more widespread interest in the tourni- quet and improve safe practice. Leslie Klenerman June 2003 ix Introduction Chapter 1 Historical Background [...]... similar instrument he had produced.3 Although Morell’s tourniquet was crude, it provided the basis for the greatly improved instrument devised by another Frenchman, Jean Louis Petit (16 74 17 50; Figure 1. 2), in the early part of the next Figure 1. 1 Morell-type tourniquet Reproduced by permission of the Wellcome Library, London, from Seerig, AWH (18 38) Armamentarium Chirurgicium Wrocław: A Gosohorsky... women usually bind up their haire withall” above the site of amputation.2 This helped to retain the maximum length of skin and muscle for the stump, controlled haemorrhage, and reduced pain The use of a stick to twist the constricting bandage was known to William Fabry of Hilden (15 60 16 24), although Morell in the Siege of Besançon (16 74) is often given credit for this (Figure 1. 1) In a work entitled... page intentionally left blank THE EARLY DEVELOPMENT of the tourniquet is bound up with the operation of amputation It was only about 14 0 years ago that the tourniquet was first used in other operations on the limbs The introduction of the bloodless field was a landmark in the development of orthopaedic operative technique, and it is interesting to recall how this came about There is evidence that limbs... the Neolithic age Hippocrates recommended cutting through the dead limb at a joint, “care being taken not to wound any living part .1 Only since Roman times have various constricting devices been employed to help the control of haemorrhage during amputation Archigenes and Heliodorus, who practised in Rome in the early part of the second century AD, used narrow bands of cloth placed directly above and. .. narrow bands of cloth placed directly above and below the line of incision, each passed two or three times about the limb and tied in a single knot This mainly controlled the venous bleeding Heliodorus then relied on tight bandaging of the stump For the next 15 00 years, no significant alteration appears to have been made in this practice Ambroise Paré in the sixteenth century advocated tying “a strong or . Kong Milan Paris Tokyo 11 11 2 3 4 5 611 7 8 9 10 11 11 2 311 1 4 5 6 7 8 9 2 011 1 1 2 3 4 5 6 7 8 9 3 011 1 1 2 3 4 5 6 7 8 9 4 011 1 211 Leslie Klenerman The Tourniquet Manual – Principles and Practice Leslie. of America 28/383 0-5 43 210 Printed on acid-free paper SPIN 10 896266 11 11 2 3 4 5 611 7 8 9 10 11 11 2 311 1 4 5 6 7 8 9 2 011 1 1 2 3 4 5 6 7 8 9 3 011 1 1 2 3 4 5 6 7 8 9 4 011 1 211 This book could. The Tourniquet Manual: Principles and Practice Leslie Klenerman Springer www.anaesthesia-database.blogspot.com The Tourniquet Manual – Principles and Practice Springer London Berlin Heidelberg New