Occlusion of arterial flow in the extremities at subsystolic pressures through the use of wide tourniquet cuffs.

Tourniquet-induced peripheral neuropathy is at least partially attributable to excessive forces applied to the nerves beneath cuffs inflated to high pressures. Lowering the inflation pressure to the minimum necessary to obtain an effective arrest of blood flow distal to the tourniquet cuff should increase the safety of these systems. Tourniquet cuffs with widths varying from 4.5 cm to 80 cm were applied to the upper and lower extremities of 34 healthy, normotensive volunteers. Occlusion pressure for the arterial system under study was estimated by determining that level of cuff inflation at which the distal pulse became detectable by ultrasonic flowmetry. The occlusion pressure was inversely proportional to the ratio of tourniquet cuff width to limb circumference and was in the subsystolic range at a cuff width to limb circumference ratio above 0.5. Wide tourniquet cuffs can achieve an effective arrest of the regional arterial circulation at subsystolic pressures of inflation. Wide cuffs may reduce the risk of tourniquet-induced injury to underlying soft tissues by lowering the inflation pressure required to secure a bloodless field.

Perineural pressures under the pneumatic tourniquet in the upper extremity.

The literature indicates that tourniquet-induced neurological injuries are relatively common and frequently occur at a subclinical level. In order to evaluate the pressure transmitted to the major peripheral nerves of the arm by an externally applied pneumatic tourniquet, a fully implantable biomedical pressure transducer was placed adjacent the radial, median and ulnar nerves in six cadaver upper extremities of average dimensions. This sensor allowed accurate, reproducible measurements of perineural pressures without requiring significant disruption of the normal anatomical structures of the test limb for its installation. At levels of tourniquet cuff inflation which are commonly used in clinical practice, there was little or no decrease in the pressure detected in the perineural regions over that applied to the surface of the limb. In addition, there was a steep gradient of perineural pressure between locations beneath the edge of the cuff and those under its midpoint. This was most marked at the highest levels of tourniquet inflation. At presently accepted levels of inflation, pneumatic tourniquet cuffs transmit high pressures to the peripheral nerves without any significant attenuation by the intervening soft tissues. The distribution of these forces is one which may subject the underlying nerves to deleterious shear forces, especially at higher levels of inflation.