The Tourniquet Manual: Principles and Practice - part 1 pot

The Tourniquet Manual: Principles and Practice Leslie Klenerman Springer www.anaesthesia-database.blogspot.com... The Tourniquet Manual – Principles and Practice... Leslie KlenermanThe

The Tourniquet Manual: Principles and Practice

Leslie Klenerman

Springer

www.anaesthesia-database.blogspot.com

The Tourniquet Manual – Principles and Practice

London Berlin

Heidelberg New York Hong Kong Milan

Paris

Tokyo

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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

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

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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

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

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THE EARLY DEVELOPMENTof the tourniquet is bound up with the operation of ampu-tation It was only about 140 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 were amputated as far back as 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 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 1500 years, no significant alteration appears to have been made in this practice Ambroise Paré in the sixteenth century advocated tying “a strong or broad fillet like that which women usually bind up their haire withall” above the site of amputation.2This 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 (1560–1624), although Morell in the Siege of Besançon (1674) is often given credit for this (Figure 1.1) In

a work entitled Currus Triumphalis e Terebintho, James Yonge of Plymouth gave an

account of a similar instrument he had produced.3Although Morell’s tourniquet was crude, it provided the basis for the greatly improved instrument devised by another Frenchman, Jean Louis Petit (1674–1750; Figure 1.2), in the early part of the next

3

Figure 1.1 Morell-type tourniquet Reproduced by permission of the

Wellcome Library, London, from Seerig, AWH (1838) Armamentarium

Chirurgicium Wroc ł aw: A Gosohorsky.