Reducing Injuries of Using Tourniquet in Surgery Settings - Essay Example

Reducing injuries caused by tourniquet in the orthopedic and plastic surgery settings Reducing injuries caused by tourniquet in the orthopedic and plastic surgery settings Writer’s Name Institution Name Reducing injuries caused by tourniquet in the orthopedic and plastic surgery settings Tourniquet is a device used in orthopaedic and plastic surgery. Orthopedics and plastic surgery are two specialties that frequently utilize pneumatic tourniquets. They are specifically designed to enable surgeons to perform delicate dissections in a bloodless operative field, hence, they are accepted and practiced universally with little question. Orthopedics is a branch of surgery devoted to the diagnosis and treatment of illnesses, injuries, deformities, and malformations of the musculoskeletal system, including bones, joints, ligaments, muscles, and tendons (Vorhaus, 2006). Orthopedists thus treat traumatic injuries to bones, such as fractures and dislocations; disturbances in joints, such as sprains, torn cartilages, or strained ligaments; and inflammation of muscle or connective tissues, such as bursitis, myositis, and tendinitis (Vorhaus, 2006). They also treat back problems, such as strains, ruptured discs, or curvatures; foot problems, such as flat feet or high arches; and neck disorders, such as strains or arthritis. Hence, orthopedic surgery entails operations on bones, muscles, and joints and allows for the replacement of hip and knee joints with artificial joints made of special metals and plastics. Fractures in bones are repaired with the implantation of pins, metal plates, and screws. These techniques greatly reduce the time needed for healing and recuperation. Plastic Surgery is another branch of surgery, dealing with the remodeling of any portion of the human body that has been damaged or deformed (Encarta 2006). The malformation may have occurred congenitally, that is, at birth, as a child born with a cleft palate or a cleft lip. Disfigurement may also be the result of injury or of deforming surgery required in treating such diseases as cancer. The primary objectives of plastic surgery are the correction of defects, the restoration of lost function, and the improvement of appearance. Reconstructive surgery, also a part of plastic surgery, involves the restoration of function to a damaged body part and the rebuilding of normal physical contours when parts of the body—such as the nose, jaw, ears, or fingers—are missing or disfigured (Encarta 2006). Cancer patients who have undergone cures of the face and neck area may also need reconstructive surgery. Facial surgery is one of the most intricate aspects of plastic surgery, requiring artistic as well as technical skills. Surgery of the hand also involves complex techniques, because of grafting of tendons and the transfer of muscles to restore usefulness to the disabled part. A major technique used in plastic surgery is grafting, the transplanting or implanting of living tissue from one part of the body to another, or from one person to another, with the expectation that the tissue will adhere and grow to supply a missing part. Several techniques of skin grafting are commonly used. One is the transfer of tissue from an adjacent part to the defect by transposition or rotation of flaps of skin. Another is full-thickness grafting and third one is called split-thickness grafting which is used especially for severe burn victims with deep burns covering large areas of the body. Other types of skin transfer are required in more complicated cases, such as those in which a full-thickness loss of the cheek or a loss of the entire nose occurs. The transplant must be nourished by blood vessels from its original site until established in its new position. Nerve grafts are also used to alleviate facial paralysis if the facial nerve has been cut off as a result of an accident. A tourniquet is defined as a constricting or compressing device used to control venous and arterial circulation to an extremity for a period of time (McEwen, 2003). It is a tightly tied band applied around a body part (an arm or a leg) in an attempt to stop severe traumatic bleeding. Severe bleeding means the loss of more than 1,000 ml (1 liter) of blood which will cause the death of the casualty in seconds to minutes (Tourniquet, 2005). Thus, pressure is applied circumferentially upon the skin and underlying tissues of a limb which is then transferred to the walls of vessels, causing them to become temporarily occluded. In surgical settings, a tourniquet is used following exsanguinations to produce a relatively bloodless operative field (McEwen, 2003). There are two distinct types of tourniquets found in the surgical setting: Non-inflatable (non-pneumatic) tourniquets constructed of rubber or elasticized cloth. Pneumatic tourniquets, which have cuffs that are inflated by compressed gas. The surgical use of non-inflatable tourniquets is very limited. In surgery today, this has largely been supplanted by the safer and more convenient use of modern electronic tourniquet systems connected to inflatable cuffs (McEwen, 2003). For pre-hospital care of a patient with trauma to an extremity, a non-pneumatic tourniquet may be employed as a last resort to control hemorrhage. A pneumatic tourniquet, on the other hand, uses a gas - inflated cuff to constrict blood flow. A regulating device on the tourniquet apparatus can be preset to control the amount of cuff pressure exerted on the limb. Pneumatic tourniquets consist of an inflatable cuff, pressure source, pressure regulator, connective tubing, and pressure display (McEwen, 2003). Tourniquets are used during some orthopedic and plastic surgeries to allow the surgeon to work in a bloodless field and reduces blood loss and facilitates identification of structures, thereby reducing operating time and reducing surgical complications (McEwen, 2003). Orthopedic uses for tourniquets include procedures undertaken to diagnose and/or correct pathology of nerves, tendons, muscles, joints, and bones of either upper or lower extremities. Examples of orthopedic procedures that utilize pneumatic tourniquets includes reduction of certain fractures, kirschner wire removal, replacement or revision of the joints of the knee, wrist, digits, hand, or elbow; arthroscopy of the knee, elbow, wrist, hand, or digits; bone grafts; graft and repair of lacerated tendons; subcutaneous fasciotomy; repair of traumatic nerve damage; carpal tunnel release; traumatic or non-traumatic amputation; correction of a hammer toe and podiatry (McEwen, 2003). The goal of plastic and reconstructive surgery is to improve a patient's self - image or level of function, thereby improving the quality of life. Plastic surgery involves primarily the subcutaneous tissue, up to and including the skin. Examples of plastic repair procedures that might utilize a pneumatic tourniquet includes repair of burn contractures, excision of lesions or tumors of the limbs and split - thickness skin grafts on burned patients (McEwen, 2003). By using a tourniquet, larger burn areas may be excised and grafted because of the bloodless field; a compression dressing is applied before the tourniquet is released. Reconstructive surgery is more extensive than plastic surgery, hence, the use of pneumatic tourniquet in this surgery includes amputations or re-plantations; repair of bone, cartilage, tendons, nerves, or blood vessels; resection of invasive tumors or lesions; repair of congenital anomalies (e.g., syndactyly or polydactyly) and bilateral extremity surgery (e.g., foot - to - hand transfer of digits, related to the amputation) (McEwen, 2003). Thus, surgical tourniquets are specifically designed to enable surgeons to perform delicate dissections in a bloodless operative field. They use compressed gas to apply a carefully controlled amount of pressure to an extremity. However, use of a pneumatic tourniquet may places the patient at risk for complications and cause serious injuries. This is because of certain patient’s size, age, or physical condition, are more likely to respond unfavorably to pneumatic tourniquet use than others or due to excessive tourniquet time or equipment malfunctioning, inadequate or nonexistent device inspection (McEwen, 2003). Injuries resulting from pneumatic tourniquet use are commonly pressure—related but may also be permanent or reversible only over extended time periods with prolonged disability being experienced by the afflicted person (McEwen, 2003). Such injuries are: Nerve Injury Post - Tourniquet Syndrome Intra-operative Bleeding Compartment Pressure Syndrome Pressure Sores and Chemical Burns Digital Necrosis Thrombosis Prolonged Swelling Toxic Reactions Other complications of pneumatic tourniquet use might include: tourniquet pain, thermal damage to tissues, hyperthermia, rabdomyolysis, and metabolic changes. Therefore, Patient safety is the primary concern when working with a pneumatic tourniquet and so the preventive measures, safe use and careful handling of pneumatic tourniquet is very important in order to reduce injuries caused by tourniquet in orthopedic and plastic surgery settings. The foremost step to be taken includes an adequate conduction of preoperative patient’s assessment. This is conducted the day before surgery is scheduled. During the preoperative assessment, the patient's physical status and medical history is reviewed, the operative limb is measured for selection of the proper size tourniquet cuff and the patient's blood pressure is recorded (McEwen, 2003). All this is the nurse's responsibility. Other then this, personnel should also demonstrate competency in use of pneumatic tourniquets in the practice setting. Preoperative personnel should be instructed in the proper operation of pneumatic tourniquets before use. Instruction and return demonstration of proper use of a pneumatic tourniquet reduces the risk of patient injury and extends the life of the pneumatic tourniquet (ARON Journal, 2002). Pneumatic tourniquets should also be cleaned, inspected, tested, and maintained before and after use according to manufacturers' written instructions i.e. preoperatively, the entire tourniquet system should be checked. The cuff, tubing, connectors, gauges, and pressure source should be cleaned and kept in working order and inspected for cracks and leaks. Connectors should be fastened securely to the tourniquet pressure source to prevent accidental deflation of the cuff during use (ARON Journal, 2002). If the cuff is damaged, it will cause: Loss of cuff pressure. Release of the cuff from around the patient's limb. Movement of the cuff on the patient's limb. Excessive leakage of cuff pressure. Pinching of tissue under the cuff leading to injury Thus, some of these failures could cause catastrophic injury, including death, to the patient by releasing blood into the surgical site or releasing a bolus of anesthetic into other parts of the body (McEwen, 2003). Cuff Pressure should also be appropriately determined. The objective is to maintain a cuff pressure that is high enough to completely suppress arterial circulation and produce a bloodless field, yet low enough to minimize the risk of neuromuscular injury (McEwen, 2003). The major mechanism of nerve injury related to the tourniquet is excessive pressure causing nerve compression. Therefore, a compromise has to be made Lower pressures have also been shown to reduce postoperative pain associated with tourniquet use. Factors affecting in determination of "minimum effective pressure" are blood pressure (patient's systolic blood pressure is an important), cuff design, fit, and snugness of application, limb circumference, state of the tissue and vascular status (McEwen, 2003) Another preventive measure to be taken includes careful determination of Limb Occlusion Pressure and optimum cuff pressure settings. For each individual limb, cuff, and cuff application there is a unique cuff pressure required to occlude arterial flow in the limb, known as the Limb Occlusion Pressure (LOP) (McEwen, 2003). The best way to optimize cuff pressure is to apply the cuff after induction of anesthesia and prior to cuff inflation and measure the LOP with the applied cuff. In order to measure the LOP, apply the cuff over the appropriate limb protection material, use a Doppler stethoscope to locate an arterial pulse distal to the cuff and slowly increase cuff pressure until the arterial pulse stops and remains stopped for several heartbeats (McEwen, 2003). LOP measurement should be made when the blood pressure is approximately stabilized to the level expected during surgery. Also apply the tourniquet at the proper location on the limb, for an appropriate period of time, and within the appropriate pressure range. Tourniquet cuff length and width should be individualized, taking into consideration the size and shape of the patient's limb and specific demands of the procedure. The widest cuff possible, based on appropriate tourniquet length should be selected. A wider bladder occludes blood flow at a lower pressure (ARON Journal, 2002). Apply the cuff to the extremity with care and attention and ensure proper fit of the cuff on the extremity in order to avoid fluid retention under the cuff (McEwen, 2003). The tourniquet cuff should be protected to keep fluids (e.g., skin prep solutions) from collecting under the cuff and causing chemical burns. The tourniquet cuff also should be protected from contamination during surgery. The cuff location should be selected such that as much tissue as possible lies between the cuff and any nerves or vascular structures. A contour cuff may be more appropriate than a straight cuff on an extremity that is highly muscular because use of contour cuffs enhances comfort and reduces risk of shearing (ARON Journal, 2002). Also apply the appropriate limb protection material to the limb in the area selected for the cuff, unless the selected cuff is specifically recommended to be used without limb protection and make sure that the limb protection material and the skin under the cuff are wrinkle – free (McEwen, 2003).Tourniquets should also be inflated rapidly. Rapid cuff inflation occludes arteries and veins almost simultaneously, preventing filling of superficial veins before occlusion of arterial blood flow. Tourniquet inflation pressure should be kept to a minimum. Intra-operative monitoring of tourniquet safety parameters also reduces the risk of complications. During the procedure, it is important to monitor the patient's blood pressure, tourniquet pressure, and tourniquet time (McEwen, 2003). Monitor the pressure display to ensure that it accurately reflects the pressure in the cuff bladder. Any sudden loss of cuff pressure intra-operatively is a cause for serious concern. If the tourniquet cuff fails for any reason, deflate it fully, and re - exsanguinate the limb before re - inflation. Re - inflation over blood - filled vasculature may lead to intravascular thrombosis (McEwen, 2003). Also monitor tourniquet inflation time and inform the surgeon regularly of elapsed tourniquet time. Comply strictly with the recommended tourniquet time limit. In addition, do not permit the tourniquet to slip or twist during limb manipulation. Hence, monitoring safety parameters during use of a pneumatic tourniquet reduces the risk for complications and patient injury (ARON Journal, 2002). At the surgeon’s request, deflate the tourniquet cuff. It should be deflated as recommended by the manufacturer. Apply pressure dressings over the incision to protect the wound from blood resurgence. Sometimes, however, the tourniquet is deflated before incisional closure in order to better identify and control bleeding. Elevate the limb 45 - 60 degrees. Transient pain upon tourniquet release can also be lessened by elevating the limb (McEwen and Shah, 2003). Deflate the tourniquet cuff rapidly to establish immediate venous return and prevent engorgement. Record the time of deflation and cuff removal and immediately remove the deflated cuff and any underlying limb protection following cuff deflation. Even the slightest impedance of venous return by the deflated cuff or padding may lead to congestion and pooling of blood in the operative field (McEwen and Shah, 2003). Check the circulation of the limb. Note the return of color to the limb and any abnormalities. Inspect the cuff site and note any signs of soft tissue damage. Additional care must be taken in bilateral procedures involving tourniquet control on two limbs, as the risk of complications and the effects of tourniquet use may be increased (McEwen, 2003). Exsanguinating and inflating the cuff on both limbs in rapid succession may cause a more pronounced blood pressure rise due to the sudden decrease in effective circulation system volume. In children, body temperature rise during surgery has been shown to be significantly greater with bilateral tourniquets compared to unilateral, and more pronounced pH drops. Last but not the least, the Preoperative Nursing Data Set nomenclature should be used when documenting on the patient record. Documentation of tourniquet use is always a nursing responsibility. Documentation includes cuff location, skin protection (e.g., padding, stockinette, gel lining), cuff pressure, time of inflation and deflation, skin and tissue integrity under the cuff before and after use of the pneumatic tourniquet, assessment and evaluation of the entire extremity, identification/serial number and model of the specific tourniquet, and identification of the person who applied the cuff (ARON Journal, 2002). Thus documentation provides information for continuity of care, retrospective review, and research of the patient's progress.  Therefore, a number of adverse reactions have been identified in relation to tourniquet use. Over pressurization may cause pain at the cuff site; muscle weakness; compression injuries to blood vessels, nerves, muscle, or skin; or extremity paralysis. Under pressurization may result in blood in the surgical field, passive congestion of the limb, shock, and hemorrhagic infiltration of a nerve. Excessive inflation time may result in excessive hyperemia, muscle weakness, ischemic injury, or extremity paralysis. Improper cuff application may lead to venous congestion, bruising, blistering, pinching, ecchymosis, or necrosis of the skin (ARON Journal, 2002). Thus, physicians are responsible for determining the correct cuff pressure and tourniquet time, but nurses share responsibilities for many of these measures. It is the nurse's responsibility to calibrate a mechanical tourniquet prior to each patient use. In addition, nurses assume responsibility for maintenance of the cuff and accessories. Hence, the preoperative nurse shares the responsibility for protecting patients from hazards related to tourniquet use. Biblography Duffy, Peter J. THE ARTERIAL TOURNIQUET 2002 Association of Ottawa Anesthesiologists (aoa) McEwen, James A. (2003) Setting Tourniquet Pressure Based on Limb Occlusion Pressure (LOP) McEwen, James A. (2003) Complications and Preventive Measures McEwen, James A. (2003) Tourniquet Use and Care Pneumatic Tourniquets Used for Regional Anesthesia, Medical Device Safety Reports (MDSR), ECRI 2005 “Recommended Practices for Use of the Pneumatic Tourniquet” AORN Guidelines on Use of Pneumatic Tourniquets, ARON Journal (2002) Shah, Harsh TOURNIQUETS Surgical Devices Omitted from Equipment Control Programs, Medical Device Safety Reports (MDSR), ECRI 2005 Dr. Teichner, Meir “TOURNIQUET SYSTEMS FOR LIMB SURGERY”, TOURNITECH LTD Tourniquet, Wikipedia encyclopedia Vorhaus, Louis J, Orthopedic, Microsoft Encarta Encyclopedia 2006 Read More