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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 2.5www.aorn.org/CE
Continuing Education Contact Hoursindicates that continuing education (CE) contact hours
are available for this activity. Earn the CE contact hours by
reading this article, reviewing the purpose/goal and objectives,
and completing the online Examination and Learner Evalua-
tion at http://www.aorn.org/CE. A score of 70% correct on the
examination is required for credit. Participants receive feed-
back on incorrect answers. Each applicant who successfully
completes this program can immediately print a certificate of
completion.
Event: #13530
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
AccreditationAORN is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center’s
Commission on Accreditation.
ApprovalsThis program meets criteria for CNOR and CRNFA recertifi-
cation, as well as other CE requirements.
AORN is provider-approved by the California Board of
Registered Nursing, Provider Number CEP 13019. Check with
your state board of nursing for acceptance of this activity for
relicensure.
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-AssistedProcedureshttp://dx.doi.org/10.1016/j.a
� AORN, Inc, 2013
RODNEY W. HICKS, PhD, RN, FNP, FAANP, FAAN;
BONNIE DENHOLM, MSN, RN, CNOR 2.5www.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.
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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 PROGRAM2.5
www.aorn.org/CEImplementing AORN RecommendedPractices 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 PROGRAM2.5
www.aorn.org/CEImplementing AORN RecommendedPractices 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