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International Journal of Orthopaedic and Trauma Nursing (2011) 15, 5761

www.elsevier.com/ijotn

Prevention of tourniquet paralysis during the use


of Pneumatic tourniquets

E D U C A T I O N
Manohar Arumugam MBBS, MS (Ortho) (Associate Professor) *

Department of Orthopaedic Surgery, Faculty of Medicine and Health Science, University Putra Malaysia,
Jalan Puchong, 43400 Serdang, Selangor, Malaysia

P R O F E S S I O N A L
KEYWORDS Summary This article focuses on the prevention of tourniquet paralysis that may
Tourniquet; arise as a result of use of modern pneumatic tourniquets. Tourniquet paralysis is an
Paralysis; injury caused by pneumatic tourniquet resulting from mechanical pressure on the
Syndrome; nerves and anoxia. The injury can range from paraesthesia to complete paralysis.
Complications; The motor functions are usually affected with sparing of sensation. High risk groups
Pneumatic; for tourniquet paralysis include older patients, hypertensive, obese patients and those
Pressure; with atherosclerosis. Adequate knowledge of the complications that can occur while
Palsy using tourniquets is important to enable nurses to prevent and detect them early.
c 2010 Elsevier Ltd. All rights reserved.

C O N T I N U I N G
Introduction tions; the most common ones reported in the liter-
ature are nerve injury, post tourniquet syndrome,
The tourniquet is a device used to create a blood- compartment syndrome, skin damage, chemical
less surgical field, enabling visualization of the ana- burns and thrombosis.
tomical structures during surgical procedures. This This article focuses on the prevention of tourni-
is especially useful in the field of hand and micro- quet paralysis that can occur as a result of the use
surgery, plastic surgery and orthopaedic surgery. of the modern pneumatic tourniquet. This is an in-
The use of tourniquets also reduces intra-operative jury caused by the use of pneumatic tourniquets,
blood loss which is a potential major complication resulting from mechanical pressure on the nerves
of orthopaedic surgery. As the patients blood pres- and surrounding structures. The injury can range
sure can fluctuate during surgery, some surgeons from paraesthesia to complete paralysis (Middleton
adopt a one glove fits all approach by applying and Varian, 1974; Flatt, 1972; Rorabeck and
300350 mm Hg of tourniquet pressure for the low- Kennedy, 1980). The occurrence is more common
er limb and 200250 mm Hg for the upper limb. in the upper limb, especially involving the radial
The use of a tourniquet is not without its complica- nerve. Involvement of the lower limb is less com-
mon. High risk groups for tourniquet paralysis
include older patients, patients with hypertension,
* Tel.: +60 193694014. those who are obese and those with atherosclerosis
E-mail address: manohar.arumugam@gmail.com (Kam et al., 2001).


1878-1241/$ - see front matter c 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijotn.2010.06.008
58 M. Arumugam

Pathophysiology picture can vary depending on which nerve is af-


fected. Wasting of the forearm muscle may be de-
Tourniquet paralysis results from excessive pres- tected at a later stage. To differentiate between a
sure (Klenerman, 1983). The pathophysiology of true division of the nerves and tourniquet palsy
localized nerve conduction block as a result of di- (which is the paralysis of the muscles of the upper
rect pressure on the nerve has been discussed by or lower limb resulting from the use of the tourni-
various authors over many decades. When they ex- quet), regular assessment of sensory and motor
plored three cases of tourniquet paralysis, Spiegel symptoms must be undertaken. In tourniquet palsy
and Lewin (1945) noted a reduction by one half to the sensory changes recover rapidly while motor
one quarter in the size of the diameter of the nerve recovery takes longer. Such dissociation between
at the site of compression. Aho et al. (1983) de- sensory and motor symptoms is suggestive of tour-
scribed a case of tourniquet paralysis that occurred niquet palsy as opposed to complete division of the
due to a faulty tourniquet gauge. Brunner (1951) nerve fibres (Eckhoff, 1931), but diagnosis is often
described palsy that occurred after using a tourni- less clear cut in the clinical situation. It is impor-
E D U C A T I O N

quet that had an error where the cuff pressure was tant to differentiate between tourniquet palsy
twice that required. Mayor and Denny-Brown and division of nerves because in the latter urgent
(1964) studied the velocity of nerve conduction at surgical intervention is required.
the site of the tourniquet and found it to be re- Pre-operative assessment should always be con-
duced when compared to the velocity proximal ducted so that pre-existing nerve lesions can be ru-
and distal to the device. Ochoa et al. (1972) found led out postoperatively. Lucas and Davies (2005)
displacement of the Nodes of Ranvier which was at have described some simple methods to clinically
its most severe under the edges of the cuff with assess the sensory and motor functions of the ra-
less displacement under the centre, suggesting dial, ulnar and median nerves. Orthopaedic theatre
P R O F E S S I O N A L

that a pressure gradient may be responsible for nurses/practitioners and anaesthetic nurses/prac-
the displacement. Rudge et al. (1974) suggested titioners can be taught how to undertake a quick
that the conduction block in the peripheral nerve assessment of the 3 main nerves of the upper limb
occurs as a result of direct mechanical effect from namely the radial, ulnar and median nerves as
the pressure applied on the nerve fibres. Fowler part of the pre-operative checklist. Any existing
et al. (1972) performed experiments with baboons neurological deficit can then be brought to the
and showed that there was constant blocking of attention of the surgeon. This can be charted on
nerve conduction when the tourniquet pressure the anaesthetic record sheet and used for later ref-
was 1000 mm Hg. There was minimal conduction erence if required. The surgeon should also be
block when the pressure was 500 mm Hg, and no responsible for performing a thorough pre-opera-
persistent conduction block when the pressure tive assessment to detect any pre-existing neuro-
was 250 mm Hg. This all suggests that tourniquet logical deficits.
C O N T I N U I N G

paralysis results from excessive pressure.


The larger nerve fibres are usually affected. Mo-
tor functions are usually affected without affecting Investigations
sensation. Since smaller diameter fibres are
spared, pain, temperature and autonomic function Seddon in 1943 (Andrew Kaye, 1991) classified
are usually preserved. Permanent deficits rarely nerve injuries into three grades, neuropraxia,
occur and most lesions heal in less than 6 months axonotmesis, and neurotmesis (Table 1) based on
(Bolton and McFarlane, 1978). Motor deficits usu- the severity of the lesion. A nerve conduction study
ally take longer to recover when compared to sen- is useful to confirm the diagnosis. In the case of
sory deficits. In the upper limb the radial nerve is true division of the nerve, the nerve conduction
the most susceptible, followed by the median and findings will be suggestive of neurotmesis where
ulnar nerves. the nerve conduction distal to the site of injury is
absent and the motor unit action potential is ab-
sent, besides this there is no anatomical continuity
Clinical diagnosis in the nerve. The findings in tourniquet paralysis
usually correspond to neuropraxia in which the
The clinical diagnosis of tourniquet paralysis is nerve conduction distal to the site of injury is pres-
made in the postoperative period when the patient ent and the motor unit action potential is absent.
is not able to move any part of the upper limb be- However unlike neurotmesis there is anatomical
low the elbow. There may be numbness and re- continuity of the nerve. Gilliatt (1980) described
duced sensation in the fingers. The clinical a double conduction block in which there is a nerve
Prevention of tourniquet paralysis during the use of Pneumatic tourniquets 59

Table 1 Identifying the three grades of nerve injury as described by Seddon.


Neuropraxia Axonotmesis Neurotmesis
Continuity of nerve Preserved Preserved May be lost
Nerve conduction Distal nerve conduction Distal nerve conduction Distal nerve conduction
studies present absent absent
Loss of function Temporary and there is May or may not recover Permanent unless nerve
recovery depending on the severity is surgically repaired
of the injury
Treatment Nerve repair not required Nerve repair not required Nerve repair required

conduction block at two levels, one occurring at faulty gauges (Klenerman, 1983). Excessive pres-
the proximal edge and the other at the distal edge sure can also be prevented by using a safety valve
corresponding to both edges of the tourniquet cuff (Wheeler and Lipscomb, 1964).

E D U C A T I O N
whereas the region between these two points The correct tourniquet pressure should be set
showed little or no change in conduction. each time the tourniquet is used as the pressure re-
quired varies from patient to patient depending on
their age and the site of application e.g. higher
Prevention pressure for the lower limb when compared to
the upper limb. Newer tourniquet machines use
Mechanical pressure, as opposed to ischaemia, has the metric system (Fig. 1). The unit for measure-
been identified as the main cause of tourniquet ment is kPa instead of mm Hg. Knowledge of con-
paralysis. Minimum tourniquet pressure suitable version from mm Hg to kPa is essential to ensure

P R O F E S S I O N A L
for the age of the patient should be used to avoid that the practitioner is using the correct pressure
tourniquet paralysis. The pressure required for an when using newer tourniquet machines (Arumu-
adult is higher than that required for children. gam, 2009) (Fig. 2 and Table 2).
Nerve injuries resulting from faulty tourniquet de- Tourniquet machines function similarly to the
vices have been reported (Kam et al., 2001; Hodg- older pneumatic tourniquets, the only difference
son, 1994; Jacobson, 1994). The pressure gauge being the units used to measure the pressure. It is
should be checked each time it is used to make sure important to ensure that the correct pressure is used
that the correct pressure has been set. Frequent every time. For application in the upper limb the
inspection and maintenance of equipment should commonly used pressure is 250 mm Hg in adults
be done to avoid excessive pressure caused by and 100 mm Hg + systolic blood pressure in children.

C O N T I N U I N G

Fig. 1 Wall mounted tourniquet machine using kPa as the unit of measurement for pressure.
60 M. Arumugam

1 atm = 760 mmHg = 101.325 kPa

1 mmHg = 101.325/760 = 0.133 kPa

1 kPa = 760/101.325 = 7.5 mmHg

atm = atmosphere

kPa = kilo Pascal

mmHg = milimetres of mercury

Example of conversion

e.g. 200 mmHg = 200 x 0.133 = 26.6 kPa


E D U C A T I O N

Fig. 2 Conversion from mm Hg to kPa.

cumference of the arm is smaller than the distal


Table 2 The kPa equivalent of some commonly used
circumference of the limb), a contoured cuff
tourniquet pressures pressure.
should be used.
Pressure in mm Hg Pressure in kPa A sleeve should be used to protect the limb. Skin
200 26.6 complication rates are lower when padding is used.
250 33.25 The padding should be wrinkle free to avoid pinch-
300 39.9 ing of the skin. Uneven padding can cause exces-
P R O F E S S I O N A L

sive pressure resulting in tourniquet palsy


(Jacobson, 1994).
Newer pneumatic tourniquet machines automat- The cuff should be applied at a location where
ically adjust the tourniquet inflation pressure there is adequate muscle mass which acts as natu-
according to the patients systolic blood pressure. ral padding, helping to avoid direct pressure on the
There are sensors to detect the limb occlusion pres- nerves and vessels. It should be positioned at the
sure (LOP) which is the minimal effective pressure point of maximum circumference of the arm. In
required to occlude the arteries (AORN, 2007). Limb the forearm it should be placed in the mid forearm
occlusion pressure is much lower than the standard (Maury and Roy, 2002; Odinson and Finsen, 2002).
pressure used for inflating a tourniquet. Estimation Nurses and other practitioners have an impor-
of limb occlusion pressure can be done by using a tant role to play and should be educated on the
C O N T I N U I N G

Doppler stethoscope and detecting a peripheral use of the pneumatic tourniquet. The tourniquet
pulse such as the radial artery pulse and slowly should be regularly checked and calibrated. Practi-
increasing the cuff pressure until the arterial pulse tioners should carefully document the following:
on Doppler stethoscope is not heard. This is the limb
occlusion pressure (LOP). The cuff pressure should  identification details of the pneumatic tourni-
be adjusted by adding a safety margin to the mea- quet device used,
sured LOP. The additional pressure added varies  the tourniquet inflation pressure,
with age and the amount of pressure used. An addi-  the duration it was applied for,
tional pressure of 50 mm Hg has been suggested for  the person who applied the tourniquet,
use with paediatric patients (Tredwell et al.,  the site where the tourniquet was applied,
2001), 30 mm Hg for LOP less than 130 mm Hg,  existence of medical conditions precluding the
60 mm Hg for LOP between 130190 and 80 mm Hg use of a tourniquet such as sickle cell anaemia
for LOP greater than 190 mm Hg (McEwen, 2006). or presence of an arterio-venous fistula in
When using a tourniquet cuff practitioners must patients with renal failure,
make sure it fits the limb properly. The ideal width  general skin condition; and peripheral pulses in
of the cuff varies according to the size and shape of the limb.
the patients limb and should be individualized.
Ideally the cuff should be wider than half the limb This information enables comparisons to be
diameter. To minimise the risk of excessive pres- made in the event of tourniquet paralysis (Murphy
sure on one edge of the cuff, especially in patients and OConnor, 2007). Adequate knowledge of the
with a tapered extremity (where the proximal cir- complications that can occur while using tourni-
Prevention of tourniquet paralysis during the use of Pneumatic tourniquets 61

quet is very important to enable practitioners to Jacobson et al., 1994. Muscle functional deficits after tourni-
prevent and detect them early. quet ischemia. American Journal of Sports Medicine 22 (3),
372377.
In the event of tourniquet paralysis, the incident Kam, P., Kevanaugh, R., Yoong, F., 2001. The arterial tourni-
should be reported to medical staff. The records quet: pathophysiological consequences and anaesthetic
and documentation should be audited and incidents implications. Journal of the Association of Anaesthetists of
and their causes analysed to help prevent future Great Britain and Ireland 58 (60), 534545.
occurrences. Machine faults should be rectified Klenerman, L., 1983. Tourniquet paralysis. Journal of Bone and
Joint Surgery 65B (4), 374375.
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Trauma Nursing, second ed. Churchill Livingstone, Edin-
burgh, pp. 105139.
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