1. INTRAOPERATIVE TOURNIQUET USE Micah Reece

2. *A caveat  As we’ve learned, pneumatic tourniquets play an important role in regional/Bier blocks but such use is outside the scope of this paper as the assigned topic is INTRAoperative tourniquet use (particularly with regards to orthopedic surgery)

3. So what is a pneumatic tourniquet?  Essentially an inflatable compression device of varying sizes containing:  Air compressor  Inflatable cuff  Connective tubing  Timer

4. Stryker SmartPump

5. How does it work?  Almost always inflated AFTER induction or block  Inflated to 100 mm Hg above systolic baseline for LE and 50 mm Hg above baseline for UE

6. How does it work?  Limb can be further exsanguinated via Esmarch bandage and elevation of extremity.

7. …But it can’t stay on forever  Most machines have a timer that will alarm after 60 minutes of inflation time  Current guidelines recommend max inflation time of 120 minutes before requiring a ten minute break for deflation of the cuff and reperfusion to the extremity

8. Why use these things?  Commonly used in orthopedic/extremity surgeries to accomplish three goals:  Minimize blood loss  Maintain a bloodless field  Aid in identifying vital structures

9. Why do WE care?! Anesthesia Considerations

10. MANY deleterious effects of inflation  Muscle breakdown and hypoxia begin almost immediately=cellular acidosis  Abolition of nerve conduction and somatosensory evoked potentials to effected area  Progressive sympathetic activation often manifests as marked hypertension, diaphoresis, and tachycardia

11. You’re not done yet! (Deflation)  Following deflation, patients will exhibit numerous transient CV changes:  lower core body temperature  decreased venous oxygen tension  sudden drops in arterial and pulmonary pressures  increased heart rate

12. Deflation Cont’d  Further hyperkalemia and myoglobinemia  Myoglobinuria  Metabolic acidosis  Think of tourniquet release as a “metabolic washout”  Respiratory Acidosis  Increased minute ventilation in a spontaneously breathing patient Lab changesRespiratory Changes

13. So what is our role?  Vigilant monitoring of hemodynamic status  Cautious use of pressors depending on when cuff is inflated/deflated  Ensure proper padding of limb, appropriate tourniquet size, minimize inflation time

14. Cont’d  Careful monitoring of pertinent labs (i.e. potassium, myoglobin, ABG)  Assess for any lingering post- operative pain or parasthesias

15. Remember!  It’s hard to have tourniquet-induced complications if the tourniquet isn’t being used. Coordinate with the surgical team to keep inflation time to an absolute minimum.

16. L is for “litigation”  It is very important for the nurse anesthetist to accurately document inflation AND deflation time  Make sure your times match those of the OR record  Also a good idea to chart that you notified surgeon at intervals of time and the message was acknowledged

17. Questions?

18. The End

19. References Barash, P. G., Cullen, B. F., Stoelting, R. K., Cahalan, M. K., Stock, M. C., & Ortega, R. (2013). Clinical Anesthesia (7th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Butterworth, IV, J. F., Mackey, D. C., & Wasnick, J. D. (2013). Morgan & Mikhail’s Clinical Anesthesiology (5th ed.). [AccessMedicine]. Retrieved from http://www.accessmedicine.com Davis, R., Keenan, J., Meza, A., Danaher, P., Vacchiano, C., Olson, R. L., & Maye, J. (2002, August). Use of a simple forearm tourniquet as an adjunct to an intravenous regional block. AANA Journal, 295-298. Retrieved from http://www.aana.com/newsandjournal/Documents/fore arm_tourniquet0802_p295-298.pdf http://www.aana.com/newsandjournal/Documents/fore

20. References Cont’d Hoerneman, D. W. (1982, December). Orthopedic surgery: Some anesthetic considerations. Journal of the American Association of Nurse Anesthetists, 555-563. Retrieved from http://www.aana.com/newsandjournal/Documents/orth opedic_surgery_1282_p555.pdf http://www.aana.com/newsandjournal/Documents/orth Nagelhout, J. J., & Plaus, K. L. (2013). Nurse Anesthesia (5th ed.). St. Louis, MO: Elsevier Saunders.