Tourniquets have come a long way in the last 30 years. Improved technology has made it possible to safely and reliably establish bloodless surgical fields in the thousands of orthopedic and non-orthopedic surgical procedures that take place every day in the United States and elsewhere. But as with all medical devices, tourniquet systems vary widely when it comes to cost, capabilities and safety features. If you're considering purchasing a system, here's what to consider.

The improvements in recent decades include a wide variety of safety features. For example, modern electronic tourniquet instruments include pressure regulators that maintain cuff pressure at the level the user sets, an automatic timer that keeps track of tourniquet inflation time, and an alarm that goes off if the inflation time exceeds the limit set by the user. Tourniquet instruments also typically include audiovisual alarms to promptly alert surgical staff if the tourniquet pressure applied by the cuff to the limb becomes hazardously high or low.

Many other safety features and alarms are also available. When you're shopping for a new tourniquet system, look for these safety-related features and alarms:

• Self-test capabilities that provide automatic checks of system operation and calibration at each start-up.
• Self-monitoring capabilities that continuously monitor the operation of the instrument.
• A backup battery that lets instruments continue to operate normally during unanticipated power interruptions and/or during patient transport.
• Alarms that detect potentially hazardous air leakage from pressurized tourniquet cuffs.
• Alarms that detect occlusions of the tubing connecting the instrument to the cuff.
• Alarms that detect the failure of a cuff to depressurize when deflation is intended.
• A cuff hazard interlock that prevents the instrument from being inadvertently powered off while a cuff is still inflated.
• Interlocks that help prevent inadvertent cuff deflation during intravenous regional anesthesia (Bier block) procedures.

TOURNIQUET TIP
Keep Cuffs From Sliding

A LITTLE DAB A thin coat of lubricating jelly can help keep tourniquets in place.

Here's a good way to keep tourniquet cuffs from slipping or moving before they're inflated. Apply a thin coat of Surgilube to the area where the tourniquet is to be placed. The webril padding sticks well to the lubricant, which helps keep the cuff from sliding. The technique is especially helpful with larger limb areas, like thighs, or with any limb that has a lot of tissue. And as the rate of obesity continues to grow, that's a problem we're dealing with more and more often. But we find it works so well, we now use it on almost everybody.

Patty Dobis, RN, CNOR, CRNFA
North Valley Hospital
Whitefish, Mont.
[email protected]

Newer safety features
At the top of the line, some manufacturers provide additional safety features that can be very useful.

• Automated estimation of limb occlusion pressure (the minimum pressure required to stop the flow of arterial blood into the limb distal to the cuff, based on a patient's limb and the location of the cuff), which lets you set safer individualized pressures.
• Integrated cuff testing, which continually monitors cuffs, tubing and connectors for leaks.
• Interfaces to OR information systems that capture cuff pressures and inflation times.
• A user interface that helps prevent inadvertent and unintended changes in cuff pressure by the user during a procedure.

Cuff considerations
You need the proper cuff selection and applications to be able to safely use tourniquets. Along with properly fitting the surgical limb, cuffs have to provide adequate surgical exposure. Be sure the system you're considering provides cuffs that fit the patient population they're intended for. Manufacturers offer cuffs in various sizes and shapes that are designed to fit a wide range of patient limbs — from the smallest pediatrics to large bariatric patients. Some manufacturers also provide matching limb protection sleeves to be used between the cuff and the limb, which can help prevent damage to the skin beneath the cuff.

TAILOR MADE Cuffs come in sizes and shapes that fit everyone from your smallest to your largest patients.

2 tubes or 1, 1 cuff or 2?
Tourniquet instruments and cuffs are commonly available in dual-port (2 tubes per cuff) or single-port (1 tube per cuff) configurations. Dual-port instruments and their corresponding cuffs have 2 separate tubing connections between the instrument and each attached cuff. One connection is used to regulate the air pressure in the cuff and the other is used to monitor the pressure in the cuff. Generally speaking, dual-port instruments and cuffs provide the most accurate and reliable indication of pressure within the cuff. That's an especially important consideration when you're using the tourniquet cuff to measure limb occlusion pressure.

Single-port instruments and their corresponding cuffs have a single tube that connects the instrument to the cuff. The connection is used to both regulate and monitor pressure. Single-port instruments and cuffs usually cost less than dual-port instruments. Either way, never use adaptors to connect single-port cuffs to dual-port instruments or to connect dual-port cuffs to single-port instruments.

Tourniquet instruments are available in single- and dual-channel configurations. Dual-channel instruments control the pressure in 2 cuffs simultaneously, which helps with bilateral and IVRA (Bier block) procedures. Each cuff channel should have independent indicators for cuff pressure and inflation time, and independent controls for cuff inflation and deflation. The controls, indicators and cuff connecting tubing should be color-coded to identify the cuff connected to each channel. Some systems include interlocks, which help prevent inadvertent cuff deflation during IVRA procedures.

Single-channel instruments, which are generally smaller and less costly, control the pressure in only 1 cuff. You can use 2 single-channel instruments together for bilateral and IVRA procedures, but again, you should never use adaptors to connect 2 or more cuffs to a tourniquet instrument intended for single-channel operation.