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Abstract

There are few clear guidelines on the proper use of tourniquets in pediatric surgery, in particular on how to set the tourniquet pressure, how to select the most appropriate cuff, and whether to use some type of soft padding beneath the cuff for limb protection. The authors could find only one published study specifically addressing pediatric cuff pressures, and no studies showing what types of cuff and/or padding create the smoothest skin surface under the cuff. Of 46 pediatric orthopaedic surgeons surveyed, 44 use a tourniquet 4.6 times per week on average and 2 have discontinued their use as a result of complications. To set cuff pressure, 13 of 44 use a standard value, 14 of 44 base pressure on age, extremity, and size, and 17 of 44 base cuff pressure on blood pressure. Thirty-four of 44 use skin protection under the cuff, but damage to the skin is common, accounting for 21 of the 67 reported complications. Nerve (15/67) and muscle (8/67) complications, related to both pressure and tourniquet time, were also reported. Using a molding and digital measurement technique, the authors compared the maximum wrinkle heights and the sums of all wrinkle heights in the skin surface under four different cuff/padding configurations. In a total of 44 trials on the upper arms and thighs of two healthy child volunteers, one type of pediatric cuff with a matching limb-protection sleeve designed and recommended by the manufacturer (Delfi) produced significantly fewer, less severe pinches and wrinkles in the skin surface than a second type of tourniquet cuff (Zimmer) with or without two layers of commonly available cast padding, and a third type (Kidde) with padding. With the second type of cuff, using cast padding reduced skin wrinkling compared to applying the same cuff on unprotected skin. In view of the survey, clinical literature, and results of this study, a guideline for use of pediatric tourniquets is proposed.

Tourniquet in Surgery of the Limbs: A Review of History, Types and Complications

“…As authors mention, this topic has not been studied largely and many of the published articles were case reports. Not many studies have been performed on tourniquet use in children ( 91 - 93 ) (to the best of our knowledge). In fact, the principles are not much different from adults.…”

Tourniquets in orthopedic surgery

“…If LOP is <130 mm Hg, the safety margin is 40 mm Hg; for LOP 131–190 mm Hg, the margin is 60 mm Hg; and if LOP is >190 mm Hg, the margin is 80 mm Hg 37. For pediatric patients, adding 50 mm Hg has been recommended 38. Studies have shown that cuff pressure based on LOP measured immediately prior to surgery is generally lower than the commonly used cuff pressures and is sufficient to maintain a satisfactory surgical field 39.…”

Tourniquet‐induced common peroneal nerve injury in a pediatric patient after knee arthroscopy – raising the red flag

“…A protocol based on measuring limb occlusion pressures (LOP), even among children, would be ideal but this practice has not been widely adopted 5. While the tourniquet time (112 min) used for our patient was within widely accepted safe limits, the inflation pressure (250 mmHg) may be too high considering his baseline SBP of 100–120 mmHg.…”

“…Currently, there are no clear or widely accepted guidelines on the use of tourniquet in both adult and pediatric settings 1, 3, 5. Most authors agree that limiting the tourniquet time to 2 h is considered ideal 1, 3.…”

“…While the lowest effective inflation pressure needed for a bloodless field had been advocated, it is still common practice among orthopedic surgeons to inflate the tourniquet to fixed pressures, for example, 250 mmHg for the upper limb and 300 mmHg for the lower limb 1. Such practices subject patients to higher than necessary inflationary pressures 1, 3, 5 (Also refer to Table S1). …”