Is tourniquet (a device used to stop blood flow) use recommended during forearm surgery?

Tourniquet Use During Forearm Surgery

Tourniquets are recommended for forearm surgery as they effectively create a bloodless surgical field, but should be used with proper technique to minimize complications.

Indications and Benefits

• Tourniquets are widely used in orthopedic surgery to create a bloodless field, which improves visualization during surgical procedures 1
• Properly applied tourniquets effectively control hemorrhage under surgical conditions 1
• Forearm tourniquets offer several advantages over upper arm tourniquets:
  • Significantly lower discomfort levels (0.39 vs 4.72 on visual analog scale) 2
  • 99% of patients experience only mild pain with forearm tourniquets compared to only 24.9% with upper arm tourniquets 2
  • Reduced muscle ischemia due to less muscle mass being compressed 2

Technique and Safety Considerations

• Forearm tourniquets should be applied at the proximal forearm with appropriate pressure (typically 250 mmHg) 3
• Tourniquet time should be minimized but patients can tolerate forearm tourniquets for up to 80 minutes (average 27 minutes) without complications 3
• Manufactured tourniquets are superior to improvised ones for safety and effectiveness 1
• Cooling of the distal limb should be considered if a tourniquet needs to remain in place for a prolonged period 1

Potential Complications and Mitigation

• Potential complications include:

  • Nerve paralysis and limb ischemia with prolonged use 1
  • Metabolic markers of muscular injury directly related to tourniquet time 1
  • Enhanced transendothelial neutrophil migration with potential for muscle injury 1

• To minimize complications:

  • Keep tourniquet time as short as possible 1
  • Use properly designed tourniquets rather than improvised ones 1
  • Consider local hypothermia of the extremity for prolonged cases to protect against adverse effects of ischemia 1

Evidence for Forearm vs. Upper Arm Tourniquets

Multiple studies have demonstrated the advantages of forearm tourniquets:

• In a study of 96 healthy subjects, forearm tourniquets caused significantly less discomfort than upper arm tourniquets 2
• A study of 93 patients showed forearm tourniquets provided bloodless fields in all operations with no complications 3
• Forearm tourniquets allow for reduced doses of anesthetic in Bier blocks, decreasing risk of systemic toxicity 4
• A randomized clinical trial found forearm tourniquets to be safe, efficient, and cost-effective compared to upper arm tourniquets 4

Clinical Application

For forearm surgery:

1. Apply a properly manufactured tourniquet at the proximal forearm
2. Use appropriate pressure (typically 250 mmHg) to ensure a bloodless field
3. Minimize tourniquet time while ensuring adequate surgical exposure
4. Consider local cooling for cases requiring longer tourniquet times
5. Monitor for signs of complications during and after the procedure

Conclusion

Forearm tourniquets represent a safe, effective, and well-tolerated approach for creating a bloodless field during forearm surgery. They cause significantly less discomfort than upper arm tourniquets while still providing excellent surgical conditions.