CONTINUING EDUCATION

Implementing AORN

Recommended Practices for Careof Patients Undergoing PneumaticTourniquet-Assisted ProceduresRODNEY W. HICKS, PhD, RN, FNP, FAANP, FAAN; BONNIE DENHOLM, MSN, RN, CNOR 2.5

www.aorn.org/CE

Continuing Education Contact Hoursindicates that continuing education (CE) contact hours

are available for this activity. Earn the CE contact hours by

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and completing the online Examination and Learner Evalua-

tion at http://www.aorn.org/CE. A score of 70% correct on the

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back on incorrect answers. Each applicant who successfully

completes this program can immediately print a certificate of

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Session: #0001

Fee: Members $15, Nonmembers $30

The CE contact hours for this article expire October 31, 2016.

Pricing is subject to change.

Purpose/GoalTo provide knowledge specific to the care of patients under-

going pneumatic tourniquet-assisted procedures in perioper-

ative practice settings.

Objectives

1. Describe changes to the updated AORN “Recommended

practices for care of patients undergoing pneumatic

tourniquet-assisted procedures.”

2. Identify contraindications to pneumatic tourniquet use.

3. Describe physiological changes associated with pneu-

matic tourniquet use.

4. Discuss safe use of a pneumatic tourniquet.

5. Identify complications that can result from pneumatic

tourniquet use.

6. Discuss perioperative nursing care of patients undergoing

a pneumatic tourniquet-assisted procedure.

382 j AORN Journal � October 2013 Vol 98 No 4

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education by the American Nurses Credentialing Center’s

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Conflict of Interest DisclosuresDr Hicks and Ms Denholm have no declared affiliations that

could be perceived as posing potential conflicts of interest in

the publication of this article.

The behavioral objectives for this program were created by

Liz Cowperthwaite, senior managing editor, and Rebecca

Holm, MSN, RN, CNOR, clinical editor, with consultation

from Susan Bakewell, MS, RN-BC, director, Perioperative

Education. Ms Cowperthwaite, Ms Holm, and Ms Bakewell

have no declared affiliations that could be perceived as posing

potential conflicts of interest in the publication of this article.

Sponsorship or Commercial SupportNo sponsorship or commercial support was received for this

article.

DisclaimerAORN recognizes these activities as CE for RNs. This rec-

ognition does not imply that AORN or the American Nurses

Credentialing Center approves or endorses products mentioned

in the activity.

http://dx.doi.org/10.1016/j.aorn.2013.08.004

� AORN, Inc, 2013

RECOMMENDED PRACTICES

Implementing AORNRecommended Practices

for Care of PatientsUndergoing PneumaticTourniquet-AssistedProcedures

http://dx.doi.org/10.1016/j.a

� AORN, Inc, 2013

RODNEY W. HICKS, PhD, RN, FNP, FAANP, FAAN;

BONNIE DENHOLM, MSN, RN, CNOR 2.5

www.aorn.org/CE

ABSTRACT

Perioperative nurses are likely to encounter the use of pneumatic tourniquets in

a variety of operative and invasive extremity procedures. Use of a pneumatic tour-

niquet offers an opportunity to obtain a near-bloodless surgical field; however, the use

of tourniquets is not without risk. Unfavorable outcomes include pain, thrombotic

events, nerve compression injuries, and disruption of skin integrity. Perioperative

nurses should be familiar with the indications, contraindications, and changes in

physiology associated with pneumatic tourniquet use. The revised AORN “Recom-

mended practices for care of patients undergoing pneumatic tourniquet-assisted

procedures” is focused on the perioperative nurse’s role in patient care and provides

guidance for developing, implementing, and evaluating practices that promote patient

safety and improve the likelihood of positive outcomes. AORN J 98 (October 2013)

383-393. � AORN, Inc, 2013. http://dx.doi.org/10.1016/j.aorn.2013.08.004

Key words: pneumatic tourniquet, pneumatic tourniquet-assisted procedures,

IV regional anesthesia, bloodless surgical field.

Surgical team members in the orthopedic,

podiatric, and plastic surgery service lines

incorporate the use of tourniquets in a host of

operative and other invasive procedures. Pneumatic

orn.2013.08.004

tourniquets are often used when a procedure requires

a near-bloodless surgical field or requires the use of

IV regional anesthesia in an extremity. Pneumatic

tourniquets are primarily used in OR settings;

October 2013 Vol 98 No 4 � AORN Journal j 383

October 2013 Vol 98 No 4 HICKSdDENHOLM

however, there may be occasions in which a nurse

who works in an emergency department (ED)

setting will assist a physician who is using a pneu-

matic tourniquet for a patient undergoing a proce-

dure with IV regional anesthesia (eg, a closed

reduction of a radial or ulnar fracture or other type

of orthopedic manipulation).1

Perioperative nurses should be familiar with the

indications, contraindications, changes in physi-

ology, and risks associated with pneumatic tourni-

quet use. This article provides a brief overview of

the AORN “Recommended practices for care of

patients undergoing pneumatic tourniquet-assisted

procedures,”2 an evidence-based document that can

help guide clinicians in patient care. For a full

understanding of each of the recommendations,

along with the corresponding review of the evi-

dence, nurses and other health care professionals

are encouraged to read the full recommended

practices (RP) document.

WHAT’S NEW

The AORN Recommended Practices Advisory

Board approved the updated “Recommended

practices for care of patients undergoing pneumatic

tourniquet-assisted procedures” in May 2013.

Compared with previous editions of the RP docu-

ment, the current document reflects a deliberate

shift from an emphasis on equipment integrity to

a focus on the perioperative nurse’s role in patient

care. As with any piece of equipment in the OR, the

integrity of the pneumatic tourniquet regulator and

its accessories remains important; however, the role

of the perioperative nurse is equally important. The

perioperative nurse’s role related to using a pneu-

matic tourniquet may not be clearly understood by

all members of the surgical team. Several of the

recommendations in the updated RP document

focus on collaboration with the surgeon and an-

esthesia professional as a key function of the

perioperative nurse who is caring for a patient

undergoing a tourniquet-assisted procedure.

The updated RP document was created using an

evidence-based approach. The lead author and a

384 j AORN Journal

doctorally prepared evidence appraiser reviewed

relevant literature and used an appraisal tool to

assign appraisal scores. The appraisal score depicts

the strength and quality of the evidence in an

individual article. The collective evidence that

supports each intervention statement was then rated

using a rating schema. Evidence rating is important

because of the growing demand for care decisions

to be based on the best evidence available. Health

care providers should recognize the importance

of being skillful in systematically translating

evidence into practice to reduce the nearly two-

decade lag between knowledge discovery and

widespread use.3,4

The previous iteration of the RP document,

updated in 2006, contained 18 recommendations;

the newly revised document contains 12. Although

the number of recommendations decreased, within

each of the new recommendations are refined

statements supported by evidence to help guide

perioperative practice. The new recommendations

incorporate suggested revisions from expert re-

viewers with extensive tourniquet experience (eg,

representatives from the AORN Neurosurgery,

Orthopedics, and Trauma Specialty Assembly;

researchers who have designed studies that address

tourniquet use). The RP document was reviewed

by national experts and representatives from or-

ganizations including the American Society of

Anesthesiologists, the American Association of

Nurse Anesthetists, and the American College

of Surgeons.

RATIONALE

Numerous opportunities exist for medical mishaps

related to the use of pneumatic tourniquets.5 Many

of the negative outcomes associated with tourniquet

use occur infrequently, but perioperative team

members should anticipate such outcomes and, to

the extent possible, plan accordingly and implement

interventions. Effective communication is required

to support the many efforts that team members

initiate to reduce the possibility of patient injury.

The newly updated RP document is intended to

RP IMPLEMENTATION GUIDE: PNEUMATIC TOURNIQUET www.aornjournal.org

provide perioperative nurses with content that can

be used to enhance their knowledge, skills, and

abilities to evaluate pneumatic tourniquet use.

DISCUSSION

The recommendations in the RP document follow

the typical sequence of events associated with

pneumatic tourniquet-assisted procedures:

n preoperative assessment,

n care plan development,

n inflation of the tourniquet cuff,

n intraoperative monitoring,

n deflation of the tourniquet cuff,

n postoperative evaluation, and

n postoperative equipment responsibilities.

Many of these recommendations are consistent

with the nursing functions of assessing, planning,

goal setting, intervening, monitoring, and prevent-

ing infection to help position the perioperative

nurse as a key member of a collaborative team that

promotes safe use of pneumatic tourniquets. Ex-

amples of the perioperative nurse’s role, along with

the descriptions, are summarized by the recom-

mendation number and presented in Table 1.

Assessing

Assessing is an important role of the perioperative

nurse. Recommendations I, VI, and VII all address

aspects of assessment. During the preoperative

assessment, the nurse should obtain a pertinent

health history.6 Based on the health history, the

nurse is able to hone in on areas of the physical

examination that warrant extra attention. For ex-

ample, a past history of coronary artery disease

may suggest impairment of the circulatory system.

Therefore, the nurse would want to inspect the

patient’s extremities and palpate to determine the

quality of peripheral pulses for any extremity that

will be affected by tourniquet use.

Medication reconciliation is a vital part of the

assessment. Identifying what medications a patient

is taking and having the patient explain the reason

for use of a medication helps uncover underlying

physiological or pathological issues. At the con-

clusion of the preoperative assessment, the nurse

has knowledge and objective findings to identify

contraindications to tourniquet use (Table 2) and

determine the risk for problems that could result

from the use of the pneumatic tourniquet. This

awareness is the focus of Recommendation I.

Patient reassessment and evaluation at the time

of pneumatic tourniquet deflation is the focus of

Recommendation VI. Perioperative nurses should

recognize that the patient’s tissues undergo anaer-

obic metabolism and circulatory occlusion when

the tourniquet is inflated. As the anesthesia pro-

fessional or surgeon deflates the tourniquet, the

patient has a systemic response to accommodate

the return of blood flow to the limb and the shift

back to normal tissue metabolism and circulation.

If the procedure required the use of regional anes-

thesia, the anesthetic agent may be released into the

circulatory system and could cause adverse effects

(eg, hypotension, seizures).7

The perioperative nurse also should assess and

evaluate the outcome of patient care after any

tourniquet-assisted procedure.2 Recommendation

VII, which is new to the RP document, directs such

nursing practice. Important nursing functions at this

point include assessment of blood loss, normalization

of temperature,8 condition of the skin that was

under the tourniquet, and circulatory function, as

well as early identification of potential complications.

Although serious patient injuries are not common,

some complications and unfavorable outcomes are

associated with the use of these devices. Compli-

cations can be physiological or mechanical, and

there is a risk that the equipment may harbor

pathogens. Table 3 describes some complications

associated with pneumatic tourniquet use. The

nurse should communicate any complications to the

surgeon, the anesthesia professional, and subse-

quent caregivers.

Planning

Another role of the perioperative nurse involves

collaborating with the surgeon and anesthesia

AORN Journal j 385

TABLE 1. Summary of the Perioperative Nurse’s Role During Pneumatic Tourniquet-AssistedProcedures

Nurse’s role Recommendation Example

Assessing I n Obtaining the patient’s historyn Determining contraindicationsn Conducting a physical examination with emphasis on inspection

and palpationVI n Evaluating the patient after deflation of the tourniquetVII n Evaluating patient outcomes after deflation of the tourniquet

Planning II n Communicating the nursing care plan to the perioperative teamn Selecting and obtaining appropriate equipment and suppliesn Verifying equipment settings

Goal setting III n Emphasizing patient safety

Intervening IV n Preparing the patientn Communicating and collaborating during the procedure

Monitoring V n Watching inflation time

Preventing infection VIII n Reducing opportunities for colonization

Educating IX n Providing or participating in education and competency verification activities

Documenting X n Documenting nursing practice

Developing policy XI n Creating and revising policies and procedures to guide practicen Taking an interdisciplinary approach to care

Improving quality XII n Assisting in evaluation and improvement of quality of caren Fulfilling the professional role

October 2013 Vol 98 No 4 HICKSdDENHOLM

professional to develop and confirm the plan of care

related to the use of a tourniquet, addressing con-

siderations related to

n preconditioning9 (ie, initiating anesthetic regi-

mens or short intervals of temporary ischemia to

reduce oxidative stress and increase skeletal

muscle ischemia tolerance related to tourniquet

inflation2),

n risk factors for deep vein thrombosis, and

n the timing of the ordered antibiotic infusion.

Collaboration activities occur preoperatively, in-

traoperatively, and postoperatively, but the central

focus of Recommendation II is creating and

386 j AORN Journal

communicating the nursing care plan for the preo-

perative phase of care for the patient undergoing

a pneumatic tourniquet-assisted procedure.2

Preoperatively, the role of the perioperative

nurse is to confirm the size and shape of the cuff,

obtain the appropriate cuff, and prepare necessary

equipment before the patient comes into the OR.

This decreases the risk of having to search for an

appropriately sized cuff and causing a delay while

the patient is in the OR andmay be under anesthesia.

The width, shape, and length of the cuff are deter-

mined based on the size and shape of the affected

extremity. Cuffs that are the wrong size have the

potential to create uneven compression, which could

TABLE 2. Potential Contraindications forTourniquet Use1

AcidosisDialysis point of access (eg, arteriovenous graft, fistula)Dietary supplements (eg, creatine)Hemoglobinopathy (eg, sickle cell disease)History of a revascularization procedure in the affected

extremityIncreased intracranial pressureInfection of the affected extremityMedications (eg, antihypertensive agents)Muscular weakness of the affected siteOpen fracture on the affected sitePeripheral vascular compromiseTumor or neoplasm distal to the tourniquet siteVenous thromboembolism

1. Recommended practices for care of patients undergoing pneu-matic tourniquet-assisted procedures. In: Perioperative Standards andRecommended Practices. Denver, CO: AORN, Inc; 2013:e25-e50.

TABLE 3. Complications Associated WithPneumatic Tourniquet Use1

Type ofcomplication Example

Physiological n Alterations in cardiac outputn Alterations in hemostasis/

thrombosisn Painn Tissue hypoxia, ischemia, or

reperfusionn Oxidative stressn Nerve conduction impairment (ie,

tourniquet paralysis)n Hypothermia

Mechanical n Injury from equipment failuren Injury from an incorrectly sized cuff

Infectious n Microbial colonization from anunclean tourniquet cuff

1. Recommended practices for care of patients undergoing pneu-matic tourniquet-assisted procedures. In: Perioperative Standards andRecommended Practices. Denver, CO: AORN, Inc; 2013:e25-e50.

RP IMPLEMENTATION GUIDE: PNEUMATIC TOURNIQUET www.aornjournal.org

affect the surgical team’s view of the operative field.

Decisions relating to cuff selection also may include

whether to use a single-bladder cuff or a dual-

bladder cuff based on the anesthesia professional’s

preference and the available equipment and whether

a sterile tourniquet is needed based on the proximity

of the cuff to the planned operative site. The nurse

should collaborate with the surgeon and anesthesia

professional to determine the lowest inflation or cuff

pressure setting possible based on the patient’s

systolic blood pressure or limb occlusion pressure.

Optimal cuff pressure should reduce the risk of

tissue injury that can result from overinflation.

Goal Setting

The nursing process allows for nurses to set goals.

Patient safety, addressed in Recommendation III,

remains one of the most important goals of nursing

practice.2 Threats to patient safety are present at

many points during tourniquet use. For example,

the perioperative nurse should be aware of the risk

that is inherent with the use of Luer connections.

Universal Luer connections have contributed to

interconnection mishaps with other medical de-

vices, such as blood pressure cuffs and IV lines and

other types of tubing.10 The RN circulator also

should verify that the tourniquet regulator is com-

patible with all associated components and that

O-rings are intact and free of cracks before use.

To help achieve the goal of safe care, nurses

should remove malfunctioning equipment from the

OR setting.11 Perioperative leaders should ensure

that polices are in place to direct equipment main-

tenance. Perioperative personnel should collaborate

with biomedical technicians to review equipment

maintenance history if there are any questions about

device integrity. Biomedical technicians maintain

equipment logs that document reported problems,

routine and unscheduled maintenance checks, and

equipment integrity inspections.

Intervening

Perioperative nurses can fulfill the function of

intervening by preparing the patient for surgery as

well as by communicating and collaborating with

perioperative team members during the procedure.

AORN Journal j 387

October 2013 Vol 98 No 4 HICKSdDENHOLM

Recommendation III provides direction for applying

padding and the tourniquet cuff. The nurse should

use low-lint padding under the cuff and should

apply the cuff snugly to the correct operative ex-

tremity in a position that creates minimal amounts

of ischemia. The perioperative nurse should

confirm the placement of both the cuff and padding

and be sure that the cuff is draped to mitigate the

risk of fluid accumulation under the cuff.

Recommendation IV focuses on communication

during exsanguination of the extremity and infla-

tion of the tourniquet.2 Before exsanguination or

inflation occurs, the perioperative team members

should discuss any health conditions the patient has

that may contraindicate the use of the tourniquet

and confirm correct laterality and the planned in-

flation pressure. The perioperative nurse should

ensure that pressure displays are visible and audible

alarms are activated at a volume that can be heard

to alert care providers to any changes in the pa-

tient’s status or problems with the equipment.

Tourniquet pressure is activated at the direction of

the surgeon or anesthesia professional.

Monitoring

Ongoing patient monitoring and equipment moni-

toring is required during tourniquet inflation, and

this serves as the basis for Recommendation V.2

Because of the tourniquet’s effect on hemody-

namics,12 inflation time should be kept to a min-

imum. An important role of the perioperative nurse

is to monitor the total inflation time and to com-

municate the duration of the inflation time to the

team at regular, established intervals. In instances

in which the inflation time is prolonged, the sur-

geon and anesthesia professional may provide ad-

justments to the plan of care. When a dual-bladder

cuff is used during IV regional anesthesia, the

patient should be monitored for pain related to cuff

inflation and complications related to the inflation

rotation sequence (eg, a bolus of local anesthesia

that results from an unplanned, sudden deflation of

the tourniquet cuff).

388 j AORN Journal

Recommendation VI focuses on monitoring and

evaluating the patient during deflation of the

tourniquet cuff. The patient may experience

rapid physiological changes (eg, decrease in core

body temperature, embolic activity, metabolic

shifts) when blood is shunted back to the ex-

tremity. The nurse should remove the padding

and cuff from the extremity after tourniquet

deflation to prevent patient injury that could be

caused by inadvertent inflation of the tourniquet.

Preventing Infection

Health care-associated infections (HAIs) are

common13 andexpensive and significantly contribute

to morbidity and mortality. Recommendation VIII

focuses on interventions that reduce the burden of

HAIs related to use of a pneumatic tourniquet.2

Although no clear evidence exists that links

contaminated pneumatic tourniquet cuffs directly to

surgical site infection, there is clear evidence that

cuffs can harbor pathogenic organisms.14 There-

fore, an important role of the perioperative nurse is

to ensure that after each use, the tourniquet regu-

lator and all reusable accessories are disinfected

according to the manufacturers’ written instruc-

tions. Single-use cuffs may be preferred when the

cuff needs to be placed near the groin or axilla,

because these areas are known to have higher

microbial counts.15 If a single-use cuff is used, the

cuff must be disposed of in a designated trash

container to avoid potential for reuse. Grossly

contaminated cuffs should be disposed of in a

manner consistent with preventing the spread of

bloodborne pathogens.

Recommendation II guides the perioperative

nurse and other members of the health care team in

helping to ensure that timing and administration of

the ordered antibiotic results in optimal tissue

concentration. In some instances, this may mean

that administration occurs at least 20 minutes

before inflation of the tourniquet cuff.16,17 In

other instances, this may mean administering the

antibiotic 10 minutes before the deflation of the

RP IMPLEMENTATION GUIDE: PNEUMATIC TOURNIQUET www.aornjournal.org

tourniquet cuff.18 The goal of optimal tissue con-

centration is to minimize the risk of an HAI.

The Final Four

The final four recommendations in each AORN RP

document discuss education/competency, docu-

mentation, policies and procedures, and quality

assurance/performance improvement. These four

topics are integral to the implementation of AORN

practice recommendations. Personnel should

receive initial and ongoing education and compe-

tency verification as applicable to their roles. Im-

plementing new and updated recommended practices

offers an excellent opportunity to create or update

competency materials and competency verification

tools. AORN’s perioperative competencies team

has developed the AORN Perioperative Job

Descriptions and Competency Evaluation Tools19

to assist perioperative personnel in verifying com-

petency or developing customized competency

evaluation tools and position descriptions.

Documentation of nursing care should include

patient assessment, plan of care, nursing diagnosis,

and identification of desired outcomes and inter-

ventions, as well as an evaluation of the patient’s

response to care. For pneumatic tourniquet-assisted

procedures, nurses should document the size and

shape of the cuff used and the total tourniquet time

as well as pressure settings. In the event of an

injury related to pneumatic tourniquet use, docu-

mentation should reflect actual patient assessment,

including the site of injury, communication with

other members of the surgical team, and actions

taken. Perioperative nurses should participate in

root cause investigations for serious injuries. If

equipment malfunction is suspected, biomedical

personnel may need to be involved in the investi-

gation. Injuries should be disclosed to the patient as

directed by organizational policy.

Policies and procedures should be developed,

reviewed periodically, revised as necessary, and

readily available in the practice setting. New or

updated recommended practices may present an

opportunity for collaborative efforts among nurses

and personnel from other departments within the

facility to develop organization-wide policies and

procedures that support the recommended

practices. The AORN Policy and Procedure

Templates, 3rd edition,20 provides a collection of

30 sample policies and customizable templates

based on AORN’s Perioperative Standards and

Recommended Practices.21 Policies for pneumatic

tourniquet use should include guidance related to

nursing assessment, preoperative planning, the

timing for prophylactic antibiotic administration,

cuff selection, the person responsible for exsangui-

nation, safe parameters for tourniquet inflation

pressures and inflation times, the interval for re-

porting tourniquet inflation time to the physician,

and equipment use.

Regular quality improvement projects are

necessary to improve patient safety and to help

ensure safe, quality care. For more details on the

final four practice recommendations that are

specific to the RP document discussed in this

article, refer to the full text of the RP document.

HOSPITAL PATIENT SCENARIO

Mrs G is a 49-year-old Hispanic woman scheduled

for a right-side total knee replacement. Her past

medical history includes type II diabetes with fair

control, essential hypertension controlled with an

angiotensin-converting enzyme inhibitor, and

osteoarthritis. She is slightly overweight, some-

thing she attributes to her osteoarthritis and the pain

she experiences when exercising. She is electively

seeking the knee replacement to improve her ability

to walk.

Nurse K meets Mrs G for the first time in the

preoperative area. After introducing herself, Nurse

K accesses the hospital’s electronic health record

and begins to complete the perioperative docu-

mentation. Nurse K reviews the active problem list,

including allergies, and reviews the patient’s

current medications. She notes when Mrs G took

her last medication doses.

Nurse K confirms with the patient which knee

is the surgical site. She then performs a physical

AORN Journal j 389

October 2013 Vol 98 No 4 HICKSdDENHOLM

examination and documents the presence of

bounding pedal pulses bilaterally. Nurse K con-

firms that the surgeon has indicated a preference

for using a pneumatic tourniquet. As she inspects

the patient’s skin, she also assesses Mrs G’s thigh

so she can select the size and shape of the tourniquet

cuff that will fit snugly. The anesthesia profes-

sional is present in the preoperative area and con-

firms with Nurse K that the preoperative antibiotic

infusion has just been completed. Together with

the anesthesia professional, Nurse K notes Mrs G’s

systolic blood pressure. With this information, they

can plan for the lowest inflation pressure that sup-

ports the surgeon’s plan of care. Nurse K trans-

ports Mrs G to the OR and helps her transfer to the

OR bed.

During completion of the preoperative briefing,

the surgeon confirms the tourniquet inflation pres-

sure and the team members verify correct laterality.

The anesthesia professional verbally reports the

timing of the completed prophylactic antibiotic

infusion and the preexisting conditions of hyper-

tension and diabetes. He then receives consensus

from the team members that the planned use of the

pneumatic tourniquet is appropriate for this patient.

Educational Resources

n AORN Video Library: Perioperative Patient Ass

Helping Patients Achieve Their Goals [DVD]. ht

.com/index.php?nav¼aorn&cat¼all.

n AORN Video Library: Prevention of Perioperativ

[DVD]. http://cine-med.com/index.php?nav¼aorn

n Denholm BG. Pneumatic tourniquets: perspective

inside & out [Webinar]. http://www.aorn.org/Eve

Previously_Recorded_Webinars.aspx#PneumaticT

n Periop 101 module: Perioperative Assessment. h

.aorn.org/PeriopModules/.

n Recommended practices for prevention of transm

tions. In: Perioperative Standards and Recommen

Denver, CO: AORN, Inc; 2013:331-363.

Web site access verified July 19, 2013.

390 j AORN Journal

Nurse K reports that she has performed an

equipment check to ensure there are no malfunc-

tions and has selected a single-use, contour cuff,

individualized to the size and circumference of Mrs

G’s leg. The anesthesia professional administers

the general anesthetic, and Nurse K applies low-

lint, soft padding to Mrs G’s leg in a manner that

avoids skin folds. She follows the manufacturer’s

instructions for applying the tourniquet cuff and

confirms that it fits snugly. She confirms that the

cuff is protected from the potential of fluid accu-

mulation from either the skin prep solution or

irrigation fluid.

After the skin prep procedure, Nurse K ascertains

that no pooling of prep solutions has occurred. The

surgeon applies the sterile drapes and then informs

the anesthesia professional that he is ready to elevate

Mrs G’s leg and apply the elastic wrap (ie, Esmarch

bandage) to exsanguinate the limb. After exsangui-

nation, the anesthesia professional inflates the tour-

niquet to the setting prescribed by the surgeon and

agreed upon during the briefing. Nurse K notes the

inflation start time and the inflation pressure on the

whiteboard.

The surgeon performs the joint replacement

essment:

tp://cine-med

e Skin Injuries

&cat¼all.

s from the

nts/Webinars/

ourniquets.

ttp://www

issible infec-

ded Practices.

procedure without difficulty.

After 85 minutes, he signals

that it is time to deflate the

tourniquet. The anesthesia

professional deflates the

tourniquet. Nurse K con-

firms that total tourniquet

time was 85 minutes. The

sterile team members mon-

itor blood loss and confirm

the pedal pulses are present

as they complete the surgical

procedure. The anesthesia

professional reports no un-

toward effects on cardiac

output or blood pressure and

no significant hypothermia.

After the sterile drapes are

removed, Nurse K confirms

RP IMPLEMENTATION GUIDE: PNEUMATIC TOURNIQUET www.aornjournal.org

that the pedal pulses are equal and of bounding

quality. Nurse K assesses Mrs G’s skin as she

removes the tourniquet cuff and padding; she

documents her nursing assessments on the peri-

operative record.

Nurse K and the anesthesia professional trans-

port Mrs G to the postanesthesia care unit (PACU)

and complete their transfer-of-care reports to the

PACU nurse. Together with the PACU nurse, they

reassess the patient’s pedal pulses and confirm

there is no change from the preoperative baseline.

After an uneventful recovery period in the

PACU, Mrs G is transferred to the orthopedic floor

and the PACU nurse completes the transfer-of-

care report. After a three-day stay, Mrs G is dis-

charged by the orthopedic nurse according to

the physician’s orders. There is no evidence of

complications.

Nurse K fulfilled the perioperative nurse’s role in

caring for Mrs G. Beginning with the preoperative

assessment, Nurse K identified the procedure and

coexisting medical conditions and performed

a pertinent physical examination. There was evi-

Resources for Implementation

n Ambulatory Surgery Center Resources [CD-ROM]. Denver, CO:

AORN, Inc; 2012. http://www.aorn.org/Education/Ambulatory/

Ambulatory_Surgery_Center_Resources.aspx.

n AORN Syntegrity� Framework. AORN, Inc. http://www.aorn.org/

syntegrity.

n ORNurseLinkTM. http://ornurselink.aorn.org.

n Perioperative Job Descriptions and Competency Evaluation Tools

[CD-ROM]. Denver, CO: AORN, Inc; 2012. http://www.aorn.org/

JobDescriptions.

n Policy and Procedure Templates [CD-ROM]. 3rd ed. Denver,

CO: AORN, Inc; 2013. http://www.aorn.org/Books_and_Publi

cations/AORN_Publications/Policy_and_Procedure_Templates

.aspx.

Editor’s notes: Syntegrity is a registered trademark and

ORNurseLink is a trademark of AORN, Inc, Denver, CO.

Web site access verified July 19, 2013.

dence of communication and

collaboration with the surg-

ical team members about the

planned procedure. Nurse K

ensured there was no skin

impingement when she

applied the cuff and no

pooling of prep solutions

underneath the cuff before

the sterile drapes were ap-

plied. During the procedure,

Nurse K monitored total in-

flation time. After the proce-

dure, she reconfirmed the

presence of pedal pulses after

the sterile drapes were re-

moved and again in the

PACU. Confirming the

timing of the preoperative

antibiotic and using the

single-use, disposable cuff

were strategies implemented to minimize the op-

portunities for Mrs G to contract an HAI.

AMBULATORY PATIENT SCENARIO

Mr J, a man in his 20s, has sustained an industrial

injury that resulted in a partial amputation of his

dominant thumb. The ED team members assess

Mr J and make preliminary plans to complete the

amputation in the ED; they will have the patient

follow up with a hand surgeon at a later date.

Fortunately, the ED physician has a consulting

relationship with a board-certified plastic surgeon

who has training in hand injury management. The

ED physician initiates a consultation request, and

the plastic surgeon is available to evaluate Mr J in

the ED setting. After the consultation, the plastic

surgeon collaborates with the ED and ambulatory

surgery center (ASC) nurses to determine that the

ASC has the capacity to immediately add Mr J to

the surgical schedule. The ED nurse administers

the preprocedural antibiotics. The surgical team re-

evaluates the previous plan of completing the

AORN Journal j 391

October 2013 Vol 98 No 4 HICKSdDENHOLM

amputation and establishes the goal of reconstructing

the injured digit.

The ASC nurse confirms that Mr J’s preoperative

history is negative for past medical illnesses, and

there are no signs of chronic medical conditions.

The RN circulator documents that she completed the

equipment check and confirms that the regulator is

functional and all accessories are compatible. The

surgeon, RN circulator, and anesthesia professional

perform a briefing with the scrubbed members of

the team. Because Mr J is healthy, the anesthesia

professional administers a general anesthetic. After

Mr J’s skin has been prepped and the sterile drapes

have been applied, the surgeon applies a sterile

disposable cuff to the patient’s forearm. The sur-

geon notifies the anesthesia professional that he is

ready to elevate Mr J’s arm and begin the exsan-

guination. The anesthesia professional inflates the

pneumatic tourniquet under the direction of the

surgeon to the agreed upon pressure settings.

After the surgeon completes the thumb recon-

struction procedure, he requests that the anesthesia

professional deflate the tourniquet. The sterile team

members monitor for bleeding at the surgical site

and apply dressings. The RN circulator records the

start and end times of the tourniquet inflation and

documents all nursing assessments. The perioper-

ative team members confirm that the total tourni-

quet time was less than 60 minutes. The anesthesia

professional reports that Mr J was hemodynamically

stable throughout the surgical procedure. The RN

circulator and anesthesia professional complete the

transfer of care to the PACU nurse. Mr J’s recovery

from the anesthetic is uneventful and he goes home

after three hours in the PACU.

In this case, prompt intervention by the ED

physician and nurses and collaboration with the

surgeon and ASC nurses saved the patient from

losing his dominant thumb. The patient’s excellent

preprocedural health placed him at low risk for

cardiopulmonary complications and facilitated the

decision to proceed with pneumatic tourniquet-

assisted surgery in an ASC setting. The RN circu-

lator adhered to the recommended practices by

392 j AORN Journal

participating in team-based collaboration about the

surgical treatment plan, ensuring the presence of

functional equipment, and documenting an accurate

account of the events. After the one-week follow-

up, the surgeon reports to the team that the patient

was very thankful that the surgical team saved his

thumb and prevented a permanent disability.

CONCLUSION

Effectively implementing the practice recommen-

dations in the “Recommended practices for care of

patients undergoing pneumatic tourniquet-assisted

procedures” should increase patient safety and

decrease elements of risk. The nursing functions of

assessing, planning, goal setting, intervening,

monitoring, and preventing infection guide the RN

in providing care to these patients. Communication

and collaboration are also key elements in safe

patient care during the use of tourniquets. Collec-

tively, the practice recommendations reflect the

best information currently available for perioper-

ative practitioners.

Acknowledgments: The authors thank Laura

Andrews, MSN, RN, CNOR, clinical nurse III,

Community Hospital of San Bernardino, CA, and

Deborah S. Hickman, MS, RN, CNOR, CRNFA,

director of surgical services and CRNFA, Renue

Plastic Surgery, Brunswick, GA, for contributing

the scenarios. The cases have been modified to

protect patient privacy.

References1. White JS. Fractures of the distal radius. Adv Emerg Nurs J.

2013;35(1):8-15.

2. Recommended practices for care of patients undergoing

pneumatic tourniquet-assisted procedures. In: Perioper-

ative Standards and Recommended Practices. Denver,

CO: AORN, Inc; 2013:e25-e50.

3. Polit DF, Beck CT. Nursing Research: Generating and

Assessing Evidence for Nursing Practice. 9th ed. Phila-

delphia, PA: Wolters Kluwer Health/Lippincott Williams

& Wilkins; 2012.

4. Fawcett J, Garity J. Evaluating Research for Evidence-

based Nursing Practice. Philadelphia, PA: FA Davis Co;

2009.

5. Odinsson A, Finsen V. Tourniquet use and its compli-

cations in Norway. J Bone Joint Surg Br. 2006;88(8):

1090-1092.

RP IMPLEMENTATION GUIDE: PNEUMATIC TOURNIQUET www.aornjournal.org

6. Hicks RW, Seibert DC. The Comprehensive Health

History and Physical Examination: A Lifespan Approach.

Lafayette, LA: Advanced Practice Education Associates,

Inc; 2011.

7. Sukhani R, Garcia CJ, Munhall RJ, Winnier AP,

Rodvold KA. Lidocaine disposition following intra-

venous regional anesthesia with different tourniquet

deflation technics. Anesth Analg. 1989;68(5):633-637.

8. Sanders BJ, D’Alessio JG, Jernigan JR. Intraoperative

hypothermia associated with lower extremity tourniquet

deflation. J Clin Anesth. 1996;8(6):504-507.

9. Van M, Olguner C, Koca U, et al. Ischaemic pre-

conditioning attenuates haemodynamic response and

lipid peroxidation in lower-extremity surgery with

unilateral pneumatic tourniquet application: a clinical

pilot study. Adv Ther. 2008;25(4):355-366.

10. Beyea SC, Simmons D, Hicks RW. Caution: tubing mis-

connections can be deadly. AORN J. 2007;85(3):633-635.

11. ECRI Institute. Optimizing an IPM program. Healthcare

Risk Control. 2009;3.

12. Klenerman L. Effect of a tourniquet on the limb and the

systemic circulation. In: The Tourniquet Manual. Prin-

ciples and Practice. London, United Kingdom: Springer-

Verlag; 2003:13-38.

13. Klevens RM, Edwards JR, Richards CL Jr, et al. Esti-

mating health care-associated infections and deaths in US

hospitals, 2002. Public Health Rep. 2007;122(2):160-166.

14. Ahmed SM, Ahmad R, Case R, Spencer RF. A study of

microbial colonisation of orthopaedic tourniquets. Ann R

Coll Surg Engl. 2009;91(2):131-134.

15. Thompson SM, Middleton M, Farook M, Cameron-

Smith A, Bone S, Hassan A. The effect of sterile versus

non-sterile tourniquets on microbiological colonisation in

lower limb surgery. Ann R Coll Surg Engl. 2011;93(8):

589-590.

16. Dounis E, Tsourvakas S, Kalivas L, Giamac‚ellou H.

Effect of time interval on tissue concentrations of ceph-

alosporins after tourniquet inflation. Highest levels

achieved by administration 20 minutes before inflation.

Acta Orthop Scand. 1995;66(2):158-160.

17. Papaioannou N, Kalivas L, Kalavritinos J, Tsourvakas S.

Tissue concentrations of third-generation cephalosporins

(ceftazidime and ceftriaxone) in lower extremity tissues

using a tourniquet. Arch Orthop Trauma Surg. 1994;

113(3):167-169.

18. Soriano A, Bori G, Garc�ıa-Ramiro S, et al. Timing of

antibiotic prophylaxis for primary total knee arthroplasty

performed during ischemia. Clin Infect Dis. 2008;46(7):

1009-1014.

19. Perioperative Job Descriptions and Competency Evalu-

ation Tools [CD-ROM]. Denver, CO: AORN, Inc; 2012.

20. Policy and Procedure Templates [CD-ROM]. 3rd ed.

Denver, CO: AORN, Inc; 2013.

21. Perioperative Standards and Recommended Practices.

Denver, CO: AORN, Inc; 2013.

Rodney W. Hicks, PhD, RN, FNP, FAANP,

FAAN, is a professor in the College of Graduate

Nursing, Western University of Health Sciences,

Pomona, CA. Dr Hicks has no declared affilia-

tion that could be perceived as posing a poten-

tial conflict of interest in the publication of this

article.

Bonnie Denholm, MSN, RN, CNOR, is a peri-

operative nursing specialist at AORN, Inc,

Denver, CO. Ms Denholm has no declared

affiliation that could be perceived as posing

a potential conflict of interest in the publication

of this article.

This RP Implementation Guide is intended to be an adjunct to the complete recommended practices document upon

which it is based and is not intended to be a replacement for that document. Individuals who are developing and

updating organizational policies and procedures should review and reference the full recommended practices

document.

AORN Journal j 393

EXAMINATION

CONTINUING EDUCATION PROGRAM

2.5

www.aorn.org/CEImplementing AORN Recommended

Practices for Care of Patients UndergoingPneumatic Tourniquet-Assisted Procedures

PURPOSE/GOAL

39

To provide knowledge specific to the care of patients undergoing pneumatic

tourniquet-assisted procedures in perioperative practice settings.

OBJECTIVES

1. Describe changes to the updated AORN “Recommended practices for care of

patients undergoing pneumatic tourniquet-assisted procedures.”

2. Identify contraindications to pneumatic tourniquet use.

3. Describe physiological changes associated with pneumatic tourniquet use.

4. Discuss safe use of a pneumatic tourniquet.

5. Identify complications that can result from pneumatic tourniquet use.

6. Discuss perioperative nursing care of patients undergoing a pneumatic-

tourniquet assisted procedure.

The Examination and Learner Evaluation are printed here for your conve-

nience. To receive continuing education credit, you must complete the Exam-

ination and Learner Evaluation online at http://www.aorn.org/CE.

QUESTIONS

1. The current AORN “Recommended practices for

care of patients undergoing pneumatic tourniquet-

assisted procedures”

1. emphasizes collaboration with the surgeon

and anesthesia professional as a key function

of the perioperative nurse.

2. includes twice as many recommendations as

the previous version of the document.

3. reflects a deliberate shift from an emphasis

on equipment integrity to a focus on the

perioperative nurse’s role in patient care.

4 j AORN Journal � October 2013 Vol 98 No 4

4. was created using an evidence-based ap-

proach that included appraisal of the relevant

literature.

a. 1 and 3 b. 2 and 4

c. 1, 3, and 4 d. 1, 2, 3, and 4

2. Potential contraindications for tourniquet use

include

1. increased intracranial pressure.

2. infection of the affected extremity.

3. muscular weakness of the affected site.

4. use of certain medications and dietary

supplements.

� AORN, Inc, 2013

CE EXAMINATION www.aornjournal.org

5. use of IV regional anesthesia.

a. 2 and 4 b. 1, 3, and 5

c. 1, 2, 3, and 4 d. 1, 2, 3, 4, and 5

3. After a pneumatic tourniquet-assisted procedure,

the perioperative nurse should assess

1. blood loss.

2. circulatory function.

3. the condition of skin that was under the

tourniquet.

4. temperature normalization.

a. 1 and 2 b. 3 and 4

c. 1, 2, and 3 d. 1, 2, 3, and 4

4. Physiological complications that can result from

pneumatic tourniquet use include

1. alterations in hemostasis.

2. nerve conduction impairment.

3. pain.

4. preconditioning.

5. tissue ischemia.

a. 1 and 2 b. 3 and 4

c. 1, 2, 3, and 5 d. 1, 2, 3, 4, and 5

5. The perioperative nurse determines the width,

shape, and length of the tourniquet cuff based on

the size and shape of the patient’s affected

extremity.

a. true b. false

6. The perioperative nurse should collaborate

with the surgeon and anesthesia professional

to determine the highest inflation or cuff

pressure setting possible based on the patient’s

systolic blood pressure or limb occlusion

pressure.

a. true b. false

7. When applying the tourniquet cuff, the perioper-

ative nurse should

1. use low-lint padding under the cuff.

2. apply the cuff snugly to the correct extremity.

3. place the cuff in a position that creates

minimal amounts of ischemia.

4. mitigate the risk of fluid accumulation under

the cuff.

a. 1 and 4 b. 2 and 3

c. 2, 3, and 4 d. 1, 2, 3, and 4

8. Tourniquet pressure is activated at the direction of

the surgeon or anesthesia professional.

a. true b. false

9. During deflation of the tourniquet cuff, the patient

may experience rapid physiological changes,

including

1. circulatory occlusion.

2. embolic activity.

3. increased core body temperature.

4. metabolic shifts.

a. 1 and 3 b. 2 and 4

c. 1, 2, and 3 d. 1, 2, 3, and 4

10. Because areas such as the groin or axilla are known

to have higher microbial counts, the surgeon may

opt to use a

a. single-use cuff. b. reusable cuff.

c. single-bladder cuff. d. dual-bladder cuff.

AORN Journal j 395

LEARNER EVALUATION

CONTINUING EDUCATION PROGRAM

2.5

www.aorn.org/CEImplementing AORN Recommended

Practices for Care of Patients UndergoingPneumatic Tourniquet-Assisted Procedures

This evaluation is used to determine the extent

to which this continuing education program

met your learning needs. Rate the items as

described below.

OBJECTIVES

To what extent were the following objectives of this

continuing education program achieved?

1. Describe changes to the updated AORN “Recom-

mended practices for care of patients undergoing

pneumatic tourniquet-assisted procedures.”

Low 1. 2. 3. 4. 5. High

2. Identify contraindications to pneumatic tourniquet

use. Low 1. 2. 3. 4. 5. High

3. Describe physiological changes associated with

pneumatic tourniquet use.

Low 1. 2. 3. 4. 5. High

4. Discuss safe use of a pneumatic tourniquet.

Low 1. 2. 3. 4. 5. High

5. Identify complications that can result from pneumatic

tourniquet use. Low 1. 2. 3. 4. 5. High

6. Discuss perioperative nursing care of patients un-

dergoing a pneumatic tourniquet-assisted procedure.

Low 1. 2. 3. 4. 5. High

CONTENT

7. To what extent did this article increase your

knowledge of the subject matter?

Low 1. 2. 3. 4. 5. High

8. To what extent were your individual objectives met?

Low 1. 2. 3. 4. 5. High

9. Will you be able to use the information from this

article in your work setting? 1. Yes 2. No

396 j AORN Journal � October 2013 Vol 98 No 4

10. Will you change your practice as a result of

reading this article? (If yes, answer question

#10A. If no, answer question #10B.)

10A. How will you change your practice? (Select all

that apply)

1. I will provide education to my team regard-

ing why change is needed.

2. I will work with management to change/

implement a policy and procedure.

3. I will plan an informational meeting with

physicians to seek their input and acceptance

of the need for change.

4. I will implement change and evaluate the

effect of the change at regular intervals until

the change is incorporated as best practice.

5. Other: ________________________________

10B. If you will not change your practice as a result

of reading this article, why? (Select all that

apply)

1. The content of the article is not relevant to

my practice.

2. I do not have enough time to teach others

about the purpose of the needed change.

3. I do not have management support to make

a change.

4. Other: ________________________________

11. Our accrediting body requires that we verify

the time you needed to complete the 2.5 con-

tinuing education contact hour (150-minute)

program:________________________________

� AORN, Inc, 2013