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2013 Perioperative Standards and Recommended Practices Last revised: November 2006. Copyright © 2013 AORN, Inc. All rights reserved.

T he following recommended practices were developed by the AORN Recommended Prac-tices Committee and have been approved by the

AORN Board of Directors. They were presented as pro-posed recommended practices for comments by mem-bers and others. They are effective January 1, 2007. These recommended practices are intended as achievable recommendations representing what is believed to be an optimal level of practice. Policies and procedures will reflect variations in practice set-tings and/or clinical situations that determine the degree to which the recommended practices can be implemented. AORN recognizes the numerous set-tings in which perioperative nurses practice. These recommended practices are intended as guidelines adaptable to various practice settings. These practice settings include traditional operating rooms, ambula-tory surgery centers, physicians’ offices, radiology departments, and all other areas where operative and other invasive procedures may be performed.

PurposeThese recommended practices provide guidelines for use of pneumatic tourniquets, which are primarily used to occlude blood flow, obtain a near bloodless field for extremity surgery, and to confine a bolus of anesthetic in an extremity for intravenous regional anesthesia (IVRA; ie, Bier block). These recom-mended practices provide information for testing, applying, and cleaning pneumatic tourniquet equip-ment, and the patient care associated with the safe use of this equipment. Pneumatic tourniquet equip-ment consists of a pressure regulator with display, connective tubing, and an inflatable cuff. These rec-ommended practices provide general guidelines for developing policies and procedures for safe use of a pneumatic tourniquet in the practice setting. Due to the variety and complexity of current pneumatic tourniquet equipment, policies and procedures should reflect considerations for the specific pneu-matic tourniquet system being used.

Recommendation I

Patient safety should be the primary consideration in evalua-tion, selection, purchase, and use of the pneumatic tourniquet and accessories.

1. Equipment selected should include technology to determine cuff pressure during use.

2. The pressure regulator should be self-calibrating upon activation.

3. If electric, the regulator should have a backup battery for use during a power failure.

4. The pressure display should be visible when-ever the cuff is inflated.

5. An audible activation indicator(s) and alarm(s) should be present and loud enough to be heard above other sounds in the OR to alert personnel to a change in pressure and lapse of a desig-nated duration of inflation time.1

6. The pneumatic tourniquet electrical cord should be flexible and adequate in length to reach the electrical outlet without stress or require the use of an extension cord.

7. Tourniquet cuffs and tubing should be compati-ble with the tourniquet regulator and other accessories. The tourniquet tubing should be incompatible with other tubing (eg, intravenous) or labeled to clearly identify that it is part of the tourniquet system. Although the US Food and Drug Administration (FDA) has not received reports of misconnections involving tourniquet tubing, over 300 cases of misconnections of other types of tubing resulting in injury have been reported.2 Many of these reports involved Luer connections. The Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) has received reports of eight deaths associated with misconnections of tubing.2

8. Tourniquet cuffs should be clean. If the cuffs are unable to be adequately cleaned, single-use cuffs should be selected.

9. A variety of sizes and shapes of tourniquet cuffs should be available to meet the needs of the patients treated in the health care organization. Contoured cuffs should be available for use on extremities of patients where there is a signifi-cant difference in circumference between the proximal and distal edges of the cuff (eg, those seen in obese patients). Pedi atric cuffs should be available for children. Injuries can result from the use of an inappropriate size or shape of cuff.

10. Pneumatic tourniquet technology continues to evolve, changing the way in which limb blood occlusion is achieved. Health care organizations and personnel should stay abreast of evolving technol-ogy and its effect on patient care and safety.

Recommendation II

The pneumatic tourniquet and its accessories should be inspected, tested, and maintained according to manufactur-ers’ written instructions.

Recommended Practices for Use of the Pneumatic Tourniquet in the Perioperative Practice Setting

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RP: Pneumatic Tourniquet1. Instructions for pneumatic tourniquet use, war-

ranties, and a manual for maintenance and inspections should be obtained from the manu-facturer and be readily available to users. Equip-ment manuals assist in developing operational, safety, and maintenance guidelines, as well as serve as a reference for appropriate use.

2. A brief set of clearly readable operating instructions should be readily accessible with each tourniquet system. These instructions should be placed on or attached to each pneumatic tourniquet for quick reference.

3. Before initial use, designated personnel within the health care organization should evaluate the pneu-matic tourniquet system for safety.

4. Each pneumatic tourniquet should be assigned an identification or serial number. This number facili-tates documenting maintenance performed on indi-vidual pneumatic tourniquets and tracking of prob-lems that occur.

5. Safety/warning alarms should be operational at all times. Lights should be operational and visi-ble. The volume of the activation indicator should be maintained at an audible level to immediately alert personnel when the pneumatic tourniquet has detected a problem.

6. Before each use, the entire tourniquet system should be checked.• If attached to a gas source, the source should be

compatible with the equipment design and the connections secure.

• The cuff, tubing, connectors, gauges, and pres-sure source should be clean and kept in working order.

• The tourniquet should be tested for integrity and function. Assuring that the tourniquet functions properly before a procedure mini-mizes the risk of pressure loss or patient injury. Most electric tourniquets automatically self-test and calibrate upon activation.

• The cuff and tubing should be inspected for cracks, leaks, and the security of the closure mechanism. Unintentional pressure loss can result from loose tubing connectors, deteriorated tubing, or cuff bladder leaks, and may result in patient injury.3

7. The pneumatic tourniquet system should be evalu-ated for safe use by designated personnel (eg, bio-medical engineering personnel) within the health care organization, at intervals consistent with the manufacturer’s written instructions and policies of the health care organization. Nerve injuries have been reported when malfunctioning equipment has caused excessive pressure.4

8. A pneumatic tourniquet that is not working prop-erly or is damaged should be removed from ser-vice immediately, along with all accessories, and reported to the designated individual responsible

for equipment maintenance (eg, biomedical engi-neering personnel).

Recommendation III

The perioperative nurse should assess the patient preopera-tively for risks and report potential contra indications to the surgeon.

Note: The operating physician determines use of a tourniquet based on the risks and benefits to the patient.

1. The perioperative nurse should assess the patient for considerations related to tourniquet use. This assessment should include, but not be limited to,• planned location of the tourniquet;• relative contraindications, including, but not

limited to,extremity infection,4,5 open fracture,4,5

tumor distal to the tourniquet,4,5

sickle cell anemia,4

impaired circulation,4-6

previous revascularization of the extremity,6

extremities with dialysis access (eg, AV shunts, fistulas),venous thromboembolism,6

increased intracranial pressure,4,5 andacidosis5;

• size and shape of the extremity;• condition of skin under and distal to the cuff

site; and• peripheral pulses distal to the cuff.

2. Prophylactic antibiotics, when ordered, should be completely infused before tourniquet cuff infla-tion. Efficacy of the prophylactic antibiotics requires tissue perfusion of the surgical site. Opti-mum tissue concentrations have been found when antibiotics were administered 20 minutes before tourniquet inflation.7,8

Recommendation IV

The pneumatic tourniquet should be connected to the appropri-ate power/gas source in a manner that minimizes risk of patient injury.

1. The appropriate gas source should be selected according to manufacturers’ written instructions. Tourniquet systems use compressed gas to apply a carefully controlled amount of tourniquet pressure. The design of the specific tourniquet system deter-mines whether this gas is nitrogen or air. Gas (either nitrogen or compressed air) may be deliv-ered from a portable canister, tank, or built-in sys-tem. Connection of the incorrect gas for inflation creates a fire hazard.3

2. Tourniquets should never be inflated with nitrous oxide or oxygen because of risk of fire.3 Some tour-niquets have an internal pump that compresses

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Recommendation V

The components of the pneumatic tourniquet should be handled in a manner that minimizes the potential for damage and risk of subsequent patient injuries.

1. The pneumatic tourniquet regulator should be securely mounted on a fixed column or pole with a tip-resistant base. Applying tension on the elec-trical cord increases the risk that it will become disconnected, frayed, or move the equipment, which may result in injuries to patients and personnel.

2. The pneumatic tourniquet regulator should be placed near the point of use and the electrical cord should reach the wall or column outlet with-out stress on the cord and without blocking a traf-fic path. Stress on the cord may cause damage to the cord, posing a hazard. The electrical cord should be free of kinks, knots, and bends that could damage the cord or cause leakage, current accumulation, and overheating of the cord’s insulation.

3. The pneumatic tourniquet plug, not the cord, should be held when it is removed from the out-let. Pulling on the cord may cause cord breakage and poses a fire hazard.

4. Tourniquet cuffs should be handled carefully. Care should be taken to avoid puncturing the cuff. Towel clips used near the cuff should be carefully placed to avoid damage to the cuff.

5. Excessive compression of the tourniquet cuff by a limb-positioning device should be avoided.

6. The pneumatic tourniquet and electrical cord should be kept dry. Pooled fluids on the floor and fluids dripping into the pneumatic tourniquet reg-ulator or electrical connections create an electri-cal hazard.

Recommendation VI

A pneumatic tourniquet cuff should be selected and applied in a manner to minimize the risk of injury to the patient.

Improper tourniquet cuff application may lead to venous congestion, bruising, blistering, pinching, ecchymosis, or necrosis of the skin.

1. The width of the tourniquet cuff should be indi-vidualized, with consideration to the size and shape of the patient’s limb. The cuff should be wider than half the limb’s diameter. Wider cuffs minimize the risk of injury to underlying tissue by dispersing pressure over a greater surface area. In clinical trials, using a wider cuff has been found consistently to occlude blood flow at a lower pres-sure in adult patients.9-14 Similar results were found using wider cuffs in children.15

2. Wider, contoured tourniquet cuffs should be used for patient extremities in which there is a tapering of the extremity between the upper and lower edge of the cuff (eg, obese, very muscular). Con-toured tourniquet cuffs have been found in clini-cal trials to occlude arterial flow at lower pres-sures than straight tourniquet cuffs of equal width.11,13,14 Contoured tourniquet cuffs minimize the risk of excessive pressure on one edge of the cuff, migration of the cuff, and a shearing injury to underlying tissue.

3. The length of the tourniquet cuff should be indi-vidualized, taking into consideration the size and circumference of the patient’s limb. The tourni-quet cuff should overlap at least 3 inches but not more than 6 inches.4 Too much overlap causes increased pressure and potential rolling or wrin-kling of underlying soft tissue. Too small an over-lap compromises effective tourniquet inflation and can result in unexpected release or inade-quate constriction.

4. The correct surgical site should be verified before application of the tourniquet cuff.

5. A soft padding should be placed around the limb, being careful to stretch the padding so that it is wrinkle-free and does not pinch the skin. In a clinical trial, the overall skin complication rate was lower when padding was used.16,17 Options include, but are not limited to, limb protection sleeves matched to the specific tourniquet cuff or two layers of stockinette stretched to fit the extremity. Materials that may shed loose fibers (eg, cotton cast padding, sheet padding) should be avoided. Lint from these materials can become embedded in the fasteners and reduce the effec-tiveness, possibly leading to an unexpected release of the cuff during the procedure.

6. Tourniquet cuffs should be applied to the verified operative extremity in a location with adequate muscle mass to protect nerves and vessels.• Upper arm and thigh tourniquets should be

positioned on the limb at the point of maximum circumference proximal to the incision.18,19

• Forearm tourniquets should be positioned mid-forearm.18,19

• Calf tourniquets should be placed with the proximal edge on the largest area of calf circumference.20

• Ankle tourniquets should be placed over the lower third of the lower leg, with the distal edge proximal to the malleoli.20-23 There is a potential risk to superficial nerves in

unprotected areas during cuff placement. When the tourniquet cuff is inflated, nerves and blood vessels are compressed.

7. To improve tourniquet cuff positioning on an obese patient’s extremity, an assistant should manually grasp the adipose tissue of the extrem-ity and gently apply and hold traction distal to

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RP: Pneumatic Tourniquetthe tourniquet site until the padding and cuff are placed. Traction should be maintained until the cuff is secured.24

8. The patient’s skin under the tourniquet cuff should be protected to prevent fluid accumula-tion (eg, skin prep solutions, irrigation) under the cuff, which may cause skin injury.

9. The cuff should be applied in its final position. If at any time a cuff position change is necessary, the cuff should be removed and reapplied. Mov-ing a cuff after placement may cause shearing of underlying tissues and subsequent injury.

10. The cuff tubing should be positioned on or near the lateral aspect of the extremity to avoid pres-sure on nerves and kinking of the tubing.

11. Reusable tourniquet cuffs should be protected from contamination by fluid, blood, and other potentially infectious material during surgery. Tourniquet protectors (eg, U-shaped drapes, adhe-sive drapes, tourniquet covers) should be used to minimize soiling.

12. The use of a single-use cuff should be considered when adequate protection of the cuff cannot be assured.

Recommendation VII

The extremity should be exsanguinated before inflation of the tourniquet.

1. The extremity should be elevated to allow venous blood to exit the limb.

2. An elastic wrap (eg, Esmarch’s bandage) should be available for exsanguination.

An elastic wrap compresses superficial blood vessels, forcing blood out of the extremity. The surgeon determines use of an elastic wrap with consideration to the risks and benefits to the patient.• Use of an elastic bandage for exsanguination

enhances the bloodless field and may mini-mize the pain associated with tourniquet use.

• Exsanguination using an elastic wrap may not be appropriate following traumatic in jury or if the extremity has been in a cast. In these instances, thrombi in blood vessels may become dis-lodged, resulting in emboli. Fatal pulmonary emboli have been reported following exsangui-nations of such extremities.25-27

• In the presence of infection, malignant tumor, or fractures in the extremity, exsan guination should be accomplished by extremity eleva-tion alone. Infection as well as malignant cells can be forced into the torso during aggressive exsanguination. Additional tissue damage can result from compressing of fractures.

3. The anesthesia care provider should be alerted before wrapping the extremity. Notification of the

anesthesia care provider facilitates monitoring for potential complications.

Recommendation VIII

Tourniquet inflation pressure should be kept to the minimum effective pressure.4,11,28,29

Overpressurization may cause pain at the tourniquet cuff site; muscle weakness; compression injuries to blood vessels, nerve, muscle, or skin; or extremity paralysis. Underpressurization may result in blood in the surgical field, passive congestion of the limb, shock, and hemorrhagic infiltration of a nerve.

1. Pressure settings should be based on limb occlu-sion pressure (LOP). Research studies have shown that occlusion can be achieved using a lower pressure when using a LOP method in conjunc-tion with a wide tourniquet cuff in adult patients.12,13,15,28,30,31 The same was found when studying children.15 Applying lower pressure has been found to result in less postoperative pain.11,31,32 Some tourniquet systems are designed to determine LOP automatically and add a safety margin to allow for fluctuations in blood pressure intraoperatively. If a standard tourniquet cuff is used, the LOP should be determined using the following steps.• Apply the tourniquet cuff over the appropriate

limb protection material.• Using a Doppler stethoscope, locate an arterial

pulse distal to the cuff. Normally, the radial artery is used on the arm and the posterior tibial artery is used on the leg. The dorsalis pedis artery may also be used for the leg.

• Slowly increase cuff pressure until the arterial pulse stops and remains stopped for several heartbeats.

• Note the cuff pressure. This is the LOP.• Deflate the cuff and confirm that the distal

pulse resumes.• Before cuff inflation, adjust the cuff pressure

setting by adding a safety margin to the LOP as follows:

add 40 mm Hg for LOP less than 130 mm Hg,add 60 mm Hg for LOP between 131–190 mm Hg, add 80 mm Hg for LOP greater than 190 mm Hg33;for pediatric patients, adding 50 mm Hg has been recommended.34

2. The LOP measurement should be made when the blood pressure is stabilized to the level expected during surgery. The LOP measurement may be completed before or after induction of anesthesia. Blood pressure at the time of LOP measurement should be documented.

3. The LOP and inflation pressure setting should be confirmed with the surgeon.

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RP: Pneumatic Tourniquet4. Inflation of the tourniquet cuff should be under

the direction of the surgeon and coordinated with the anesthesia care provider.

5. After limb exsanguination and cuff inflation, there is an increase in blood volume to vital organs and a subsequent increase in systolic blood pressure.4 Coordination with the anesthesia care provider facilitates management of the patient during this rapid physiologic change.

6. Pneumatic tourniquets should be inflated rapidly. Rapid tourniquet cuff inflation occludes arteries and veins almost simultaneously, preventing fill-ing of superficial veins before occlusion of arterial blood flow.

7. While the tourniquet cuff is inflated, the pressure gauge or digital display should be clearly visible and monitored for excessive fluctuation. Nerve damage may result from excessive tourniquet pressure or uneven padding.35 Catastrophic neuro-logical complications (eg, permanent nerve palsy) can occur with excessive tourniquet inflation pressures.36

Recommendation IX

Pneumatic tourniquet inflation time should be kept to a mini-mum and deflation managed to minimize risks to the patient.

Excessive inflation time may result in venous en gorgement, hyperemia, muscle weakness, ischemic injury, or extremity paralysis. Neurological complica-tions have been found to be associated with longer inflation times.37

1. The surgeon should be informed of the duration of the tourniquet time at regular, established intervals. Use of a timer and audible alarm on the tourniquet regulator facilitates this communica-tion. Serious patient injury, including extremity paralysis, may result from prolonged inflation of the tourniquet.38-40 Safe tourniquet inflation time has not been precisely determined. The time var-ies with the patient’s age, physical status, and the vascular supply to the extremity. There is general agreement that inflation time should not exceed 60 minutes for an upper extremity and 90 min-utes for a lower extremity.33 In pediatric patients, inflation times of less than 75 minutes for lower extremities has been recommended.41

2. When prolonged tourniquet time is desired, the tourniquet should be released for reperfusion of the limb every hour. The reperfusion time should be 15 minutes, after which the tourniquet may be reinflated for another full period as above. Reperfu-sion allows oxygenation and continued viability of the tissue. Fifteen minutes of reperfusion after one hour has been found to minimize the tissue inflam-matory response and is recommended.42-45

3. Deflation of the tourniquet should be coordinated with the anesthesia care provider. Physiologic

changes resulting from deflation of the tourniquet are dependent upon the relative size of the extremity, duration of tourniquet time, and over-all physiologic status of the patient. A decrease in blood pressure occurs as blood is shunted to the extremity.4 A significant decrease in core body temperature occurs upon deflation of a lower extremity cuff.46,47 Products of anaerobic metabo-lism enter the circulation upon deflation of the cuff causing a transient hyperemia and a mixed respiratory/metabolic acidosis. This results in a decrease in oxygen saturation and increase in end-tidal carbon dioxide. In a study measuring emboli released upon cuff deflation, the highest number were released within one minute of defla-tion.48 Coordination with the anesthesia care pro-vider or perioperative registered nurse monitoring the patient facilitates management of the patient’s physiologic status during this rapid change.

4. Pneumatic tourniquets should be deflated as rec-ommended by the manufacturer. The cuff and sleeve/padding should be removed from the extremity upon deflation of the tourniquet. Even the slight impedance of venous return by the pad-ding or deflated cuff may lead to congestion and pooling of blood at the surgical site.34

Recommendation X

The patient should be monitored continuously with special con-sideration to pain and temperature while the tourniquet cuff is inflated.

1. Pain should be assessed and managed. After infla-tion of the pneumatic tourniquet for 30 to 60 min-utes, patients may experience “tourniquet pain,” accompanied by an increase in heart rate and blood pressure.4,49

2. The patient’s temperature should be continuously monitored during use of a pneumatic tourniquet. In pediatric and adult patients, inflated tourniquets result in an increase in core body temperature.41,50

3. Care should be exercised to avoid overheating the patient while the tourniquet cuff is inflated, partic-ularly in pediatric patients.51,52

Recommendation XI

The perioperative registered nurse should evaluate the outcome of the patient care at the end of the procedure.

1. The patient should be continuously monitored for 15 minutes after deflation of the pneumatic tourniquet. • A decrease in blood pressure occurs as blood is

shunted to the extremity. • Products of anaerobic metabolism enter the cir-

culation upon deflation of the tourniquet cuff, causing transient hyperemia and a mixed respiratory/metabolic acidosis. This results in a decrease in oxygen saturation.41,49,53

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RP: Pneumatic Tourniquet• Increases in end-tidal carbon dioxide occur.41,49,54-56

The time for clearance of the metabolites depends upon the patient’s physiologic status, extremity involved, and duration of tourniquet inflation.

• A decrease in core body temperature typically occurs upon deflation of a lower extremity tourniquet cuff.46,47,50

• An increase in intracranial pressure can occur.43,57

• An embolism can be released from the extrem-ity upon deflation of the tourniquet cuff.58-62

In a study of patients undergoing total knee arthroplasty, blood pressure dropped immediately upon tourniquet cuff deflation and remained depressed for 15 minutes. Metabolites were reab-sorbed within 30 minutes of deflation.54 The peak number of emboli released occurs within 60 sec-onds of tourniquet cuff deflation.56

2. The immediate postoperative evaluation should include, but not be limited to,• vital signs, including oxygen saturation;• skin condition under the tourniquet (eg, tem-

perature, color, integrity);• pulses distal to the tourniquet cuff; and• temperature.

3. Use of the pneumatic tourniquet and patient out-comes should be reported during patient hand off to other caregivers.63

4. Any complications should be reported to the sur-geon and anesthesia care provider and discussed during the hand off of care to other caregivers.

5. Potential complications include, but are not lim-ited to,• injury to skin, muscle, nerves, and vessels

underneath the tourniquet cuff;• hematoma;• edema;• circulatory impairment distal to the tourniquet

cuff, venous congestion, or emboli;• damage to nerves distal to the tourniquet

cuff20,37,64;• wound effusion;• compartment syndrome65-68; and• pulmonary embolism.48,69-71

Serious injuries due to the use of pneumatic tourniquets are uncommon, but the risk is pres-ent. The risk of pulmonary emboli has been found to be associated with duration of tourniquet time.4,48 Neurological complications have also been found to be associated with longer tourni-quet times.37

Recommendation XII

Additional care should be taken in procedures involving tourniquet control on two extremities because the risk of complications and the systemic effects of tourniquet use may be increased.

1. The perioperative registered nurse, surgical team, and anesthesia care provider should be familiar

with the respective placement of the tourniquets when using tourniquets on more than one extrem-ity. Labeling the tubing to each cuff minimizes the risk of inflating/deflating the wrong cuff.

2. Blood pressure should be closely monitored. Exsanguination and inflating the cuff on both extremities in rapid succession may cause a more pronounced blood pressure rise due to the sudden decrease in effective circulation system volume.

3. Temperature should be monitored and care should be taken not to overheat the patient with warming devices. In studies of children, the rise in core body temperature is significantly greater with bilateral tourniquets compared to a single tourniquet.34,41

4. When tourniquets are used on more than one extremity, the first tourniquet cuff inflated should be completely deflated (and the cuff and limb protection removed, if possible) to assure circula-tion in the first limb has been restored. Problems related to incomplete tourniquet deflation could go unnoticed throughout the second limb procedure.

5. If possible, tourniquet deflations should be staggered 30 to 45 minutes apart to reduce the rapid release of large amounts of metabolic by-products into the vascular system. Tourniquet use causes anaerobic metabolism, which produces lactic acid and other metabolites. Lactic acidosis causes a decrease in vascular resistance and allows an increased blood flow when the tourni-quet is deflated. The larger the muscle mass expe-riencing ischemia from the tourniquet, the greater the production of these metabolic by-products. Sequential deflation lessens the potential for adverse patient reactions to these by-products.72 In children, when simultaneous deflation of bilat-eral tourniquets occurred, systolic blood pressure decreased 8–10 mm Hg and a greater decrease in pH was seen.41

Recommendation XIII

Potential patient injuries and complications associated with intravenous regional anesthesia (IVRA [ie, Bier block]) should be identified and safe practices should be established.

1. Tourniquet users should be familiar with the inflation-deflation sequence when using a dual-bladder cuff and when using two single-bladder cuffs together for IVRA. Severe injuries and deaths have occurred when the wrong cuff was deflated.73

2. Patient assessment and tourniquet application before IVRA should include, but not be limited to, allergies to local anesthetics.

3. The appropriate tourniquet cuff should be selected.

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RP: Pneumatic Tourniquet• A dual-bladder tourniquet cuff and extra con-

nective tubing are generally required.• A wider placement site is needed because of

the additional width of the dual-bladder tour-niquet cuff.

• A higher pressure is generally required because each cuff bladder is narrower.

4. The tourniquet user should be fully aware of which cuff is proximal, which cuff is distal, and the inflation/deflation status of each at all times. Labeling or color-coding of the tubings to these cuffs facilitates identification.2

5. The tourniquet should be deflated gradually as determined by the physician to minimize the potential for an adverse reaction. As the tourniquet cuff deflates, the anesthetic agent is released into the circulatory system, causing systemic effects.

6. The perioperative registered nurse circulator should be aware of the patient’s physiological sta-tus. Adverse reactions to local anesthetic agents are potential complications of IVRA. A bolus of local anesthesia entering the general circulation can occur when there is a sudden deflation of the tourniquet, from deflation soon after injection of local anesthetic, or if the bolus is released too rapidly at the end of the procedure. The sudden rush of anesthetic and metabolites into the circu-latory system affects the central nervous system (eg, ringing in the ears, tingling, numbness, loss of consciousness, seizures) and the heart.

Recommendation XIV

The pneumatic tourniquet and accessories should be cleaned after each use.

1. After use, personnel should turn off the pneu-matic tourniquet, clean all reusable parts, and inspect these parts according to the manufactur-er’s written instructions.

2. Reusable cuffs and bladders should be cleaned, rinsed, and dried between patients using a US Environmental Protection Agency (EPA) regis-tered, intermediate-level, tuberculocidal disinfec-tant. The cuff and bladder should be rinsed thor-oughly because cleaning solution residue may cause skin irritation, increase the chance of aller-gic reaction, and decrease the life of the cuff and bladder. If a cuff is unable to be cleaned ade-quately, it should be discarded in an appropriate receptacle.

3. All tubing should be cleaned, rinsed, and dried between patients and before storage, using an EPA-registered, detergent/intermediate-level disinfec-tant. Care must be taken to prevent introduction of solutions into the ports. Water in the ports contrib-utes to microbial growth. Subsequent deflation of wet bladders may cause minute droplets of solu-tion to be forced into the tourniquet regulating mechanism, causing damage.

4. Single-use cuffs should be discarded in an appro-priate receptacle.

5. Tourniquet components contaminated with blood or other potentially infectious material should be cleaned with an enzymatic solution and an EPA-registered, intermediate-level disinfectant.

Recommendation XV

Patient assessments, the plan of care, interventions imple-mented, and evaluation of care related to use of a pneumatic tourniquet should be documented.

1. The Perioperative Nursing Data Set (PNDS), the uni-form perioperative nursing vocabulary, should be used to document patient care and to develop poli-cies and procedures related to pneumatic tourni-quets on the intraoperative patient record. The expected outcomes of primary importance to these Recommended Practices are “The patient is free from signs or symptoms of injury due to equipment, instrumentation, sponges, or sharps.” This outcome falls within the domain of Safety. The associated nursing diagnoses may include “ineffective tissue perfusion,” “risk for impaired skin integrity,” and “risk for impaired peripheral neurovascular func-tion.” The associated interventions that may lead to the desired outcome may be “Implements protective measures to prevent skin/tissue injury due to mechanical sources,” “Uses supplies and equip-ment within safe parameters,” “Evaluates for signs and symptoms of physical injury to skin and tis-sue,” “Identifies baseline tissue perfusion,” “Assesses factors related to risks for ineffective tis-sue perfusion,” and “Evaluates postoperative tissue perfusion.”74

2. Documentation should include, but not be lim-ited to,• pneumatic tourniquet system identification

serial number,• calibrations,• cuff pressure,• skin protection,• location of tourniquet cuff,• skin integrity under the cuff before and after

use of the pneumatic tourniquet,• the person placing the tourniquet cuff,• time of inflation and deflation, and• assessment and evaluation of the entire

extremity.

3. Documentation of tourniquet testing should reflect the biomedical equipment identification number and/or serial number date of inspection, preven-tive maintenance, and status of all equipment. Records of equipment failure and preventative maintenance assist in identifying equipment per-formance problems or hazards and minimize risk of patient injury and equipment failure.

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Recommendation XVI

Education, competency assessment, and validation should be conducted before the perioperative registered nurse manages the care of a patient using a pneumatic tourniquet.

1. Education of personnel operating pneumatic tour-niquets should include, but is not limited to,• indications and contraindications,• physiologic changes during and after tourni-

quet use,• risks to patients, • precautions to minimize these risks, • proper operation of the tourniquet regulator,• proper cuff application, • measurement of LOP,• documentation and communication,• corrective actions to employ in the event of a

patient injury, and• proper care and handling of the tourniquet and

accessories. Tourniquets and accessories have been associ-

ated with patient injuries. Education provides a foundation to guide safe patient care and mini-mize these risks.

2. Periodic educational programs should be pro-vided as reinforcement of principles and intro-duction of new technology and procedures. This periodic education should include, but is not lim-ited to,• changes in technology or procedures, • compatibility of equipment and accessories,• potential hazards, and• precautions to be taken.

4. Administrative personnel should ensure that assessment and documentation of initial and annual personnel competency in the safe use of pneumatic tourniquets and accessories is per-formed. Individual competency assessment should include, but is not limited to,• contraindications, • risks, • assessment of the skin under the cuff before

and after use, • assessment of limb perfusion before and after

use, • pre-use equipment checks,• appropriate gas source,• appropriate cuff selection, • appropriate cuff pressure,• approved duration and communication of tour-

niquet times, and• required documentation.

Incorrect pneumatic tourniquet use can result in serious patient injury. Competency assurance verifies that personnel have knowledge of the use of the pneumatic tourniquet and appropriate cor-rective action taken in the event of a patient injury. This knowledge is essential to minimizing the risks of misuse of the equipment and provid-ing a safe environment of care.

Recommendation XVII

Policies and procedures for pneumatic tourniquets should be developed, reviewed periodically, revised as necessary, and read-ily available in the practice setting.

1. Policies and procedures for the pneumatic tourni-quet should include, but are not limited to,• safety features required on pneumatic

tourniquets;• equipment maintenance programs;• supplemental safety monitors required;• equipment checks before initial use; • reporting and impounding malfunctioning

equipment; • preoperative, intraoperative, and postoperative

patient assessments;• responsibility for cuff application; • precautions during use;• reporting of injuries;• potential adverse events; • care and cleaning of the tourniquet after use;

and• documentation.

2. The frequency, method, and criteria for pneu-matic tourniquet testing should be established according to manufacturers’ written instructions. A pneumatic tourniquet management program assists in identifying equipment problems that may have adverse effects on patient safety.

3. These recommended practices should be used as guidelines for developing policies and procedures in the practice setting. Policies and procedures establish authority, responsibility, and account-ability. They also serve as operational guidelines and guide development of performance improve-ment activities.

Recommendation XVIII

The health care organization’s quality management program should include investigation of adverse events and near misses associated with use of a pneumatic tourniquet.

1. Adverse patient outcomes and near misses associ-ated with use of a pneumatic tourniquet should be collected, analyzed, and used for performance improvement as part of the health care organiza-tion’s system-wide performance improvement program. To evaluate the quality of patient care and formulate plans for corrective action, it is necessary to maintain a system of evaluation.

2. If a patient injury or equipment failure occurs, the pneumatic tourniquet system (eg, regulator, tub-ing, cuff) must be handled in accordance with the Safe Medical Devices Act of 1990, amended in March 2000.75 Device identification, maintenance and service information, and adverse event infor-mation should be included in the report from the practice setting. Retaining the regulator, tubing,

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Glossary

Bier block: A regional anesthetic involving occlud-ing blood flow to and from the extremity and infusing local anesthetic agent intravenously into the extremity.

Contoured cuff: A tourniquet cuff with a distal edge shorter than the proximal edge, creating a funnel-like shape when applied to an extremity.

Compartment syndrome: A pathologic condition caused by the progressive development of arterial com-pression and consequent reduction of blood supply. Clinical manifestations include swelling, restriction of movement, vascular compromise, and severe pain or lack of sensation.

Exsanguination: The process of forcible expulsion of blood from an extremity before tourniquet use. The term also means massive blood loss.

Limb occlusion pressure (LOP): The unique cuff pres-sure required to occlude arterial flow in the limb.

Pneumatic: Pertaining to gas or air; filled with com-pressed gas or air.

Regulator: The mechanical device controlling the inflation, deflation, cuff pressure, and alarms for a tourniquet.

Shearing: A sliding movement of skin and subcuta-neous tissue that leaves the underlying muscle stationary.

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Publication HistoRy

Originally published April 1984, AORN Journal. Revised November 1990.

Published as proposed recommended practices March 1994. Revised November 1998; published December 1998. Reformatted July 2000.

Revised November 2001; published February 2002, AORN Journal.

Revised 2006; published in Standards, Recom-mended Practices, and Guidelines, 2007 edition.

Minor editing revisions made to omit PNDS codes; reformatted September 2012 for publication in Periop-erative Standards and Recommended Practices, 2013 edition.

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