You are on page 1of 7

Hemostasis and Tourniquet

Ravi Arvind Karia, MD

Achieving hemostasis is vital for any surgical procedure. Modern techniques of hemostasis
have revolutionized extremity surgery. Achieving a bloodless field allows for the execution
of more complex procedures in terms of the ease of anatomic dissection and minimizing the
length of surgery. Strategies to achieve hemostasis start before the incision with purpose-
ful preoperative planning and the use of a tourniquet. Although the tourniquet is thought to
be vital in extremity surgery, it is not without complication. Ischemic damage to muscle,
pressure damage to nerves, and the systemic effects of reperfusion all limit the duration of
its use and introduce potentially significant complications. Once bleeding is encountered,
hemostasis can be obtained using various techniques. Direct pressure is the simplest
method of controlling bleeding and can also be used to gain necessary time to mobilize
other agents or methods in a life-threatening situation. The electrocautery device, similar to
the tourniquet, is an important component but can introduce potentially devastating com-
plications. A thorough understanding of how the device works is necessary in preventing
these complications. Finally, a large variety of hemostatic agents exist to aid in achieving
coagulation via both mechanical and chemical methods.
Oper Tech Sports Med 19:224-230 2011 Elsevier Inc. All rights reserved.

KEYWORDS hemostasis, electrocautery, tourniquet

T echniques for obtaining hemostasis in the surgical field


have been vital for the evolution of modern surgery,
likely second only to anesthetic advances. Achieving a blood-
preoperative history and physical examination should
prompt a laboratory workup. The standard tests include a
platelet count, Partial thromboplastin time, Prothrombin
less field allows for the execution of more complex proce- Time/International Normalized Ratio, and in select situations
dures in terms of ease of anatomic dissection and minimizing a bleeding time.1
the length of surgery. Both historic and modern techniques Another important step in the preoperative period is form-
are presented in this article. ing a surgical plan. The simplest method for limiting blood
Although often clich, everything in medicine starts with a loss and keeping a clear surgical field involves selecting ap-
history and physical examination. This preoperative workup proaches through bloodless planes and diligent soft-tissue
is crucial for the avoidance of surgical complications and dissection. These methods have been previously discussed in
intraoperative surprises. Surgical patients, in particular, this journal.
should be questioned about their surgical and bleeding his- To achieve hemostasis once the surgery commences, the
tory. For example, does the patient have a propensity for surgeon faces the decision of allowing the body to clot natu-
easily bruising or swelling, does the patient have an acquired/ rally or to surgically stop the bleeding immediately. The ax-
familial coagulopathy (such as von Willebrand disease), or is iom all bleeding will eventually stop is often true but leads
the patient currently on medications (eg, coumadin and as- to increased blood loss, obstruction of surgical visualization,
pirin) that could result in complications? Discussing previous and postoperative hematoma formation with increased de-
surgeries, even minor dental procedures, can shed light on velopment of associated wound complications. Surgical
issues that can be easily dealt with during the preoperative methods to stop bleeding can also have adverse effects. Many
period. Major past surgeries or any concerning data on the methods of surgical hemostasis cause direct tissue damage,
introduce foreign material into the wound, and take away
precious anesthetic time. Each surgery/surgeon has its mix
Department of Orthopaedics, University of Texas Health Science Center at between these 2 extremes of hemostasis.
San Antonio, San Antonio, TX.
Address reprint requests to Ravi Arvind Karia, MD, UT Health Science Cen-
Direct pressure is the simplest method for achieving he-
ter San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229. E-mail: mostasis. It is often stated that the finger is the best tool for
karia@uthscsa.edu controlling bleeding, generally until a more long-standing

224 1060-1872/11/$-see front matter 2011 Elsevier Inc. All rights reserved.
doi:10.1053/j.otsm.2011.02.004
Hemostasis and tourniquet 225

method can be used. Small-caliber vessels can definitively be quired to occlude arterial blood flow decreases as cuff width
controlled with direct pressure alone. The pressure slows increases. Larger individuals, either more muscular or obese,
blood flow and subsequently allows platelets to congregate tend to have limbs that are more conical than cylindrical. In
and initiate the clotting process. Applying direct pressure to these instances, a curved cuff allows better positioning of the
the edges of a surgical incision on approach can often control tourniquet and subsequently even spread of pressure (Fig.
most skin bleeders before they become significant. 1).7,8 A significant drawback is that curved cuffs are not as
The use of direct pressure is also advantageous in cases readily available as the standard cylindrical cuffs. As stated
with substantial bleeding. When operating in a deep wound, earlier, contoured cuffs have been proven to require less pres-
such as the hip/pelvis or operating on a coagulopathic pa- sure for achieving arterial occlusion. However, if a contoured
tient, direct compression packing with sponges is beneficial cuff is unavailable, a simple technical trick can be performed
to control bleeding. In these situations, it is often impossible by requesting an assistant to pull the skin/soft tissues distally
to control each individual bleeding vessel directly. Packing to create a more cylindrical surface for cuff application. Clin-
can be used for a few minutes before continuing the surgical ical benefits of the wider/contoured cuffs have not been de-
procedure or a few days in a trauma/damage control situa- termined. No studies show a decrease in incidence of nerve/
tion. muscle injury or postoperative complications. Logic alone
The direct pressure method provides the surgeon and sur- stands in favor of the use of contoured cuffs for better fit and,
gical team much needed time when a major vessel is injured thus, even the spread of pressure in larger patients.
and/or bleeding becomes emergent. This time confers the The use of padding under tourniquet cuffs is intended to
ability to obtain other hemostatic devices or mobilize addi- minimize complications. The use of soft padding helps to
tional personnel in an emergent situation. In addition, the relieve pressure points caused by skin wrinkles or the under-
anesthesia team has time to catch up with the blood loss, side of the cuff itself. Studies have been performed to test the
and other surgeons can be called in to help control the bleed- type of soft padding that should be used to maximize results.
ing. Controlling bleeding from a major vessel often requires Olivecrona et al9 used total knee arthroplasty patients in 3
visualizing the vessel in an undisturbed field. This may re- randomized groups to receive elastic sleeves, soft cast pad-
quire an extension of the current surgical approach or creat- ding, or nothing under a tourniquet cuff. The primary end-
ing a new one. One must always remember the basic surgical point measured was blistering under the cuff site. No patients
tenet of working from known to unknown when dealing with the elastic sleeve developed blisters (0/33). Blisters de-
with these situations. veloped in twice as many patients with nothing under the
tourniquet (7/30) compared with soft cast padding (3/29).
However, the authors mentioned that those patients resulting
Tourniquet in blisters experienced significantly longer lengths of tourni-
The surgical tourniquet, used to confer a bloodless field for quet time. Interestingly, more patients resulted in blisters
visualization and limit total blood loss, has been present for using a contoured tourniquet compared with a standard cy-
many centuries and has been imperative in the advancement lindrical design.9
of extremity surgery. A pioneer in hand surgery, Sterling Exsanguination is another important factor in achieving
Bunnell stated that operating on a hand without a tourniquet successful tourniquet use. An improved bloodless field is
is like trying to fix a watch in a bottle of ink.2 The evolution established by manually squeezing the blood from extremity
of the tourniquet, from a tight ligature to a microprocessor- vessels before inflating the tourniquet. This is generally ac-
aided pneumatic device, has allowed a decrease in trouble- complished using an elastic wrap (either rubber or Ace-type
some complications associated with using pressure to slow wrap [3M]) with the limb held in elevation. Contraindica-
blood flow. However, the use of a tourniquet can still be tions to this include fragile skin that is susceptible to shear-
dangerous if simple guidelines are not followed. We review ing, tumors for fear of spread via manual force to adjacent
these guidelines along with the scientific basis behind them. tissues, and infection. However, Green3 has stated through
The modern tourniquet is derived from the invention of a personal experience to have seen no untoward reaction from
pneumatic tourniquet by Harvey Cushing in 1904 and has this practice when dealing with infection.
since revolutionized extremity surgery.3-6 Current models are It would be inaccurate to say there is such a thing as a safe
computerized, allowing for direct control of pressure settings tourniquet time. Soft-tissue damage and the risk of compli-
and alarms that can be set for specified time points. Devices cations from tourniquet use start with insufflation. Common
using a nitrogen/oxygen tank are now rare, making regular practice uses 2 hours as a safe cutoff time to avoid irreversible
inspections less troublesome and intraoperative issues, such complications. Multiple studies have looked into what con-
as tank depletion, less frequent. Despite these advances, reg- stitutes safe tourniquet time, but most remain inconclusive
ular inspection of the pressure gauges is important because except for stating that complications with tourniquet use ex-
imprecise measurements can exacerbate over time with re- ist and are exacerbated with an extended duration of use.
peated use. A study by Wilgis10 is likely the most-cited reference re-
The first parameter to consider when deciding to use a garding the subject of tourniquet time. Levels of pH, PO2, and
tourniquet is the size and shape of the cuff. The best choice PCO2 were measured before tourniquet insufflation, for the
for a cuff is one that fits the shape of the extremity and evenly duration of the procedure (a maximum of 2 hours), and then
spreads pressure. Studies have shown that cuff pressure re- after until values normalized. The authors examined the ef-
226 R.A. Karia

Figure 1 (A) The use of a tourniquet on an obese thigh can be challenging. The circular tourniquet often does not fit well
evident by the space between the cuff and padding. This can lead to uneven pressure distribution as well as the need
to use higher cuff settings. (B) A simple trick to make the obese thigh more circular involves having an assistant pull on
the thigh pannus distally while the tourniquet is tightened. (C) As shown, this allows for a better fit with a standard cuff.

fects of these levels on muscle fatigue/damage, nerve damage, lose structural features, making dissection difficult, and sub-
coagulation issues, and edema. Citing basic science research, sequent edema makes wound closure arduous.1,2 There is no
they concluded that muscle fatigue might not be reversible current recommendation on this practice.
after 2 hours secondary to significant acidosis (pH below 7). Reperfusion of tissues is not simply a local tissue event.
Significant coagulation deficiencies that develop with acido- Not only is a fresh supply of oxygenated blood and nutrients
sis can lead to postoperative hematoma formation. Further- returning to the exsanguinated extremity, but also renewed
more, significant edema formation may be caused by de- blood flow allows for the flushing of toxic metabolites and
creased oxygen tension allowing for increased capillary other substances. The local environment consists of acidosis,
permeability. It is important to note that the use of a tourni- hyperkalemia, and byproducts of muscle breakdown such as
quet longer than 2 hours was not studied. After 2 hours of myoglobin that are released into the systemic stream. These
tourniquet use, it took more than 15 minutes for the mea- together can act upon many systems by perturbing coagula-
sured parameters to normalize.10 tion, causing inflammatory pulmonary reactions, and renal
Some surgeons have advocated deflating the tourniquet for tubular damage. In addition, if surgery-specific substances,
a period during surgery to allow reperfusion. No scientific such as cement or large fat emboli, are trapped by a tourni-
evidence supports this practice. In fact, those with personal quet, these too can be released suddenly en masse into the
experience using this technique have reported that tissues system.3,5,10 Knowledge of this would force one to be more
Hemostasis and tourniquet 227

vigilant in the immediate posttourniquet period. Ensuring would be sensible to wall off the cuff and padding with an
intra- and postoperative hydration is of prime importance in impervious drape before surgical prepping and replace pad-
alleviating some of these potential complications. Further- ding should it get wet during the course of the surgery.
more, most would agree that the use of bone cement (poly- Likely, the most common complication in tourniquet use
methyl methacrylate) and significant work in the intramed- is nerve injury. Often, nerve damage from tourniquet use
ullary canal (ie, reaming) should not be performed under goes underreported because of the expected changes in the
tourniquet. extremity for patients who have just undergone surgery.
There is controversy in terms of whether the tourniquet Nerve damage is closely related to direct pressure compared
should be released before wound closure or after the dressing with muscle damage that is related to ischemia.5 Nerves un-
is applied. It would seem appropriate to release the tourni- dergo a neurapraxia and recovery in which the time to recov-
quet before wound closure if dissection was performed near a ery is spontaneous and difficult to predict. It has been shown
vital vessel, such as the radial artery in the volar forearm/wrist that larger myelinated nerves are more susceptible to pres-
procedures.2,3 In other locations, this may not pertain. After sure related damage. The primary microscopic damage is
prolonged tourniquet use, small-caliber vessels that cause a evident around the nodes of Ranvier, which become dis-
prolonged ooze are difficult to control because of the local placed under the pressure of the tourniquet. Recovery time is
environment as discussed previously. This may be better expected to correlate with the time required to repair the
controlled with a wound closure and a compressive dressing. displacement of nodes of Ranvier and subsequent damage
Studies on total knee arthroplasty have shown decreased caused to surrounding myelin.13
blood loss with tourniquet release after wound closure. How- Muscle is known to be the most sensitive tissue to ischemic
ever, these results are tempered with an increased need for damage. As with nerve injury, muscle damage related to tour-
reoperation, presumably for complications from hematoma niquet use is likely underreported. Postoperatively, extremi-
formation.4 A consensus has not been reached on this sub- ties are not expected to function normally; damage from the
ject. The risk of bleeding based on the specific surgical site surgery itself weakens the muscles, and pain limits postoper-
must be considered along with the added risk of increased ative motion and strength. Furthermore, extremities that are
tourniquet usage. immobilized postoperatively are often not examined for
To determine an adequate pressure setting for the tourni- strength/motion, adding to the difficulty in determining what
quet, the goal should be to select the lowest pressure possible components of these deficiencies are related to muscle isch-
while still achieving arterial occlusion. Most commercially emia by the tourniquet. Ischemic muscle damage is charac-
available tourniquets do not accomplish this task, with rec- terized by damage to muscle cells resulting in edema and
ommendations of adding anywhere from 50 to 150 mm Hg decreased contractility, leading to stiffness, weakness, and
over systolic blood pressure, generally lower in the upper pain. Generally, permanent damage in uninjured muscle is
extremity and higher in the lower extremity. Although this evaded by limiting ischemia to less than 3 hours.14 However,
usually allows a bloodless field, overshooting is probable and this may not be surgically relevant because the surgery itself
consequential. McEwen, who is credited for developing the often causes some muscle damage in addition to the injury
modern computerized tourniquet, has developed a system to that prompted the surgery. The situation is further compli-
handle the issue of overshooting pressure settings. He uses a cated by nerve damage related to tourniquet use affecting
sensor that can be placed distally on the extremity (described objective postoperative measures. Simply looking clinically
as being similar to a pulse oximeter) that allows the tourni- (and not separating nerve and muscle damage), it is noted
quet to achieve the lowest possible pressure setting. After the that weakness and decreased motion can persist for weeks to
sensor determines the lowest pressure needed to occlude the months after tourniquet use. The application of a tourniquet
pulse, a set amount is added to account for variables, such as in an animal model has shown incomplete return to pretour-
the change in blood pressure and collateral circulation. Using niquet strength at 3 weeks.15 Electromyographic changes can
this technique, the study reports significant decreases in persist for 5 months.16 As expected, both show less adverse
pressure settings compared with traditional methods.11 As clinical affects with decreased tourniquet times and pres-
discussed earlier, there is no safe usage time for tourniquets. sures.
The damage to underlying soft tissue begins immediately,
and those tissues most likely to incur significant damage are
the underlying skin, muscle, and nerves. Direct Control
Previously, we discussed blistering of the skin; however,
burning of the skin is another devastating complication that
of Bleeding Vessels
is also easily preventable. Burning has been shown to occur Medium- to large-caliber vessels are generally best dealt with
when surgical preparatory substances (especially those with using suture to tie them off. This adequately controls the
high alcohol content) are allowed to run down and soak the vessel during surgery and helps avoid the complication of
cuff padding. These substances are held under high pressure postoperative bleeding that could lead to hematoma forma-
on the skin surface for extended periods causing burns. Dick- tion or reoperation. Vessels are isolated from surrounding
inson and Bailey12 described this phenomenon in a study in soft tissue to limit soft-tissue trauma and clamped to stop
which they noted that burns only resulted from preps with blood flow. A standard tie uses a free suture (generally silk or
high alcohol content. Regardless of the preparatory type, it Vicryl [Ethicon Inc.]) to wrap around the tips of the clamp. A
228 R.A. Karia

minimum of 4 knots are placed opposite to the tip of the energy is imparted per unit area. A small contact area forces
clamp. After the first knot, the clamp may be temporarily the energy to reach the pad through a small area of skin
released (flashed) to ensure that the vessel is closed off. causing severe burns. Therefore, grounding pads need to
An alternative method is the stick tie. The suture is passed have good solid contact. This can be achieved by first shaving
in a figure-8 pattern through the vessel end via a needle. The and cleaning the site and then using a pad with a precoated
vessel is then tied off in standard fashion. This method has substance to enhance contact. Also, it is imperative to place
been shown to be more secure and less likely to loosen.17 the grounding pad away from previously implanted metal
objects, such as fracture fixation plates or joint arthroplasty
implants. Ideally, the grounding pad should be located closer
Electrosurgery to the surgical field than the implants. Finally, it is essential to
The use of an electric current to cauterize vessels has been in always keep the electrosurgery device in clear view and away
practice for over 80 years. Dr William Bovie is generally cred- from any exposed skin. There have been reports of the device
ited with the development. Henry Cushing was the first to being misplaced under an extremity and with manipulation
use it in an operating room. The basic principle for this or pressure being turned on, causing severe damage at a site
method is the use of electric current to cause local tissue away from the surgical field (Fig. 2).
heating resulting in thermal coagulation. The modern Bovie
device allows for multiple settings and strengths for tissue
dissection and/or hemostasis. The most commonly used set-
Hemostatic Agents
tings are coagulate and cutting, mixed with varying strengths. Hemostatic agents can be divided into 3 main groups: those
Electrosurgery devices also come in bipolar and monopolar that aid in the prevention of bleeding, those that mechani-
types. Bipolar devices have the electrical current pass directly cally act to stop bleeding, and those that act to chemically
from 1 electrode to another, with the tissue being cauterized/ enhance hemostasis. Generally speaking, hemostatic agents
cut in between. Monopolar devices transmit the current di- are most helpful in controlling bleeding via small-caliber vessels
rectly to the tissue, and the current travels through the body and can be used pre-, intra-, and postoperatively. Epinephrine is
to a grounding pad applied away from the surgical field to the most commonly used agent to prevent bleeding. Often
complete the circuit. Although monopolar devices allow for teamed with an anesthetic agent, such as lidocaine, epinephrine
more freedom and ease of use, the bipolar devices impart less is injected into the surgical site before incision. It is usually
energy to the tissues and surrounding tissues, minimizing diluted to a level of 1:20,000 to 1:2 million and works by caus-
damage. ing diffuse vasoconstriction. It is very helpful in decreasing
When using these devices in the coagulate mode, the cur- bleeding from small-caliber skin bleeders, which thereby en-
rent is released in rapid pulses. This causes the tissue to heat hances surgical visualization and saves time from having to deal
up to a maximum of 60C. This confers protein denaturation with them. Drawbacks to epinephrine include concern over sys-
and slow water evaporation, leading to tissue desiccation and temic absorption of the drug and its use in the most distal of
coagulation of small caliber vessels. In contrast, in the cutting extremities. Some surgeons have advocated against using epi-
mode, the current is constant, causing tissue heating to nephrine in digit surgery because of the concern of necrosis.
100C. This results in immediate tissue lysis as the cautery tip Mechanical agents include bone wax and Gelfoam (Phar-
cuts through the tissue.18 macia & Upjohn, Kalamazoo, MI). Bone wax is a mixture of
The use of electrosurgery is not without consequence. beeswax and Vaseline (Unilever) that can be directly applied
Both local soft-tissue damage in the surgical field and burns at to bleeding bony surfaces to locally stop the bleeding in the
the site of the grounding pad are possible but easily avoid- surgical field. This works well for small-caliber bleeders but
able. Excessive use of the electrosurgery device destroys an- poorly for bleeding from large surface areas, such as exposed
atomic tissue planes and prevents reliable healing. A few cancellous bone surfaces. Although bone wax is generally not
simple basic principles can prevent excessive soft-tissue dam- absorbed and thought to be quite benign, it has been blamed
age within the surgical wound. First, when using a monopo- for local inflammatory reactions.
lar device to cauterize a vessel, holding the lumen up using Gelfoam is a highly porous, gelatin-based product origi-
forceps and a clamp prevents electric current from damaging nally developed to help fill in bony defects. This was unsuc-
surrounding tissues. This method takes less time to achieve cessful, and it has since been noted that the substance helps
coagulation, and, therefore, less energy is imparted on the to tamponade bleeding in a focal area characterized by a slow
tissues. Electric current passes best through liquid. There- ooze. Gelfoam gets absorbed by the body within about 4
fore, keeping the surrounding field dry is imperative for tar- weeks and has very little local inflammatory reaction. There
geting the heat to the desired location. Finally, using the have been no adverse reports of leaving Gelfoam in place
coagulate mode to cut through tissue is not recommended once the procedure is completed.19
because dissection takes longer and, therefore, produces Chemical agents act to enhance clot formation in terms of size
more surrounding tissue damage. and/or speed. Surgicel is a product containing cellulose and
Burns to areas outside the surgical field are possible as hematin. When blood is exposed to Surgicel (Ethicon Inc.), an
well. As stated earlier, in a monopolar device, the current artificial clot is created followed by the commencement of the
passes from the probe through the body to a grounding pad. clotting cascade. Again, this substance is generally only indi-
The wider the surface area accepting the current, the less cated for slow vessel ooze and not significant bleeding. Although
Hemostasis and tourniquet 229

The other chemical agents are thrombin and fibrin glue.


Thrombin used clinically has historically been bovine in or-
igin although human forms are now available. Thrombin acts
chemically to clot fibrin found naturally in the native clot.
Thrombin is generally available as a spray to cover a large area
requiring hemostasis. Additionally, soaking sponges with
thrombin for packing enhances their effect. For thrombin to
be active, the fibrinogen level must be greater than 50 mg/dL
and, therefore, not necessarily ideal for a coagulopathic pa-
tient. Thrombin has been noted to be especially helpful in
treating those patients who have been on heparin or heparin-
like medications.20 Fibrin glue acts in a similar fashion to
thrombin but contains fibrinogen as well as thrombin. If
thrombin and fibrinogen are mixed prematurely, a clot
forms, and, therefore, these 2 substances need to be sepa-
rated in the packaging. Oftentimes, this product is available
as a double-barrel spray so the thrombin and fibrinogen are
mixed upon contacting the wound.20

Conclusions
Achieving hemostasis is vital for any surgical procedure. He-
mostasis strategy starts before the incision with purposeful
preoperative planning and the use of a tourniquet. Although
the tourniquet has revolutionized extremity surgery, it is not
without complication. Ischemic damage to muscle, pressure
damage to nerves, and the systemic effects of reperfusion all
limit the duration to which a tourniquet can be used. Once
bleeding is encountered, hemostasis can be obtained via var-
ious techniques of direct pressure, electrocautery, tying of the
vessels, and hemostatic agents.

References
1. Edmunds L: Hemostasis problems in surgical patients, in Colman R
(ed): Hemostasis and Thrombosis: Basic Principles and Clinical Prac-
tice (ed 5). Philadelphia, PA, Lippincott Williams & Wilkins, 2006, pp
1103-1119
2. Flatt A: Tourniquet time in hand surgery. Arch Surg 104:190-192, 1972
3. Green DP: Basic principles, in Green D, Hotchkiss R, Pederson W, et al
(eds): Greens Operative Hand Surgery (ed 5). Philadelphia, PA,
Elsevier, 2005, pp 11-16
4. Noordin S, McEwen J, Kragh J, et al: Surgical tourniquets in orthopae-
dics. J Bone Joint Surg Br 91:2958-2967, 2009
5. Bruner JM: Safety factors in the use of the pneumatic tourniquet for hemo-
stasis in surgery of the hand. J Bone Joint Surg Br 33:221-224, 1951
6. Wakai A, Winter D, Street JT, et al: Pneumatic tourniquets in extremity
surgery. J Am Acad Orthop Surg 9 5:345-351, 2001
7. Pedowitz RA, Gershuni DH, Botte MJ, et al: The use of lower tourniquet
inflation pressures in extremity surgery facilitated by curved and wide
Figure 2 An inadvertent burn by the bovie is an easily avoidable com- tourniquets and an integrated cuff inflation system. Clin Orthop Relat
plication. It is important to keep the device clear of all exposed skin Res 287:237-244, 1993
when not in use. (A) Shown here is a burn on the posterior thigh skin 8. Crenshaw AG, Hargens AR, Gershuni DH, et al: Wide tourniquet cuffs
caused by an assistant accidently leaning on the electrocautery device more effective at lower inflation pressures. Acta Orthop Scand 59:447-
451, 1988
while retracting. (B) At two week follow-up the wound has yet to heal
9. Olivecrona C, Tidermark J, Hamberg P, et al: Skin protection under-
fully. (C) At 3 months, wound has healed but scar still visible.
neath the pneumatic tourniquet during total knee arthroplasty. A ran-
domized controlled trial of 92 patients. Acta Orthop 77:519-523, 2006
10. Wilgis EFS: Observations on the effects of tourniquet ischemia. J Bone
Joint Surg Br 53:1343-1346, 1971
Surgicel can be left in the wound after closure, it has been 11. Younger A, McEwen J, Inkpen K: Wide contoured thigh cuffs and
known to cause increased scarring and even be caustic in certain automated limb occlusion measurement allow lower tourniquet pres-
patients. sures. Clin Orthop Relat Res 428:286-293, 2004
230 R.A. Karia

12. Dickinson JC, Bailey BN: Chemical burns beneath tourniquets. BMJ 17. Sherris D, Kern E (eds): Basic Surgical Skills. Rochester, MN, Mayo
297:1513, 1988 Clinic Scientific Publishing, 1999, pp 78-83
13. Ochoa J, Fowler T, Gilliatt R: Anatomical changes in peripheral nerves 18. Reinhold R: Selected technologies and general surgery, in OLeary J
compressed by a pneumatic tourniquet. J Anat 113:433-455, 1972 (ed): The Physiologic Basis of Surgery (ed 2). Baltimore, MD, Williams
14. Sapega A, Heppenstall R, Chance B, et al: Optimizing tourniquet ap- and Wilkins, 1996, pp 640-642
plication and release times in extremity surgery. A biochemical and 19. Seeber P, Shander A: The chemistry of hemostasis, in Seeber P, Shander
ultrastructural study. J Bone Joint Surg Br 67:303-314, 1985 A (eds): Basics of Blood Management. Malden, MA, Blackwell Publish-
15. Mohler L, Pedowitz R, Lopez N, et al: Effects of tourniquet compression ing, 2007, pp 77-95
on neuromuscular function. Clin Orthop Relat Res 359:213-220, 1999 20. Czinn E, Chediak J: Coagulation and hemostasis, in Salem M (ed):
16. Saunders K, Louis D, Weingarden S, et al: Effect of tourniquet time on post- Blood Conservation in the Surgical Patient. Baltimore, MD, Williams
operative quadriceps function. Clin Orthop Relat Res 143:194-199, 1979 and Wilkins, 1996, pp 45-78

You might also like