Pediatric tourniquets: analysis of cuff and limb interface, current practice, and guidelines for use

There are few clear guidelines on the proper use of tourniquets in pediatric surgery, in particular on how to set the tourniquet pressure, how to select the most appropriate cuff, and whether to use some type of soft padding beneath the cuff for limb protection. The authors could find only one published study specifically addressing pediatric cuff pressures, and no studies showing what types of cuff and/or padding create the smoothest skin surface under the cuff. Of 46 pediatric orthopaedic surgeons surveyed, 44 use a tourniquet 4.6 times per week on average and 2 have discontinued their use as a result of complications. To set cuff pressure, 13 of 44 use a standard value, 14 of 44 base pressure on age, extremity, and size, and 17 of 44 base cuff pressure on blood pressure. Thirty-four of 44 use skin protection under the cuff, but damage to the skin is common, accounting for 21 of the 67 reported complications. Nerve (15/67) and muscle (8/67) complications, related to both pressure and tourniquet time, were also reported. Using a molding and digital measurement technique, the authors compared the maximum wrinkle heights and the sums of all wrinkle heights in the skin surface under four different cuff/padding configurations. In a total of 44 trials on the upper arms and thighs of two healthy child volunteers, one type of pediatric cuff with a matching limb-protection sleeve designed and recommended by the manufacturer (Delfi) produced significantly fewer, less severe pinches and wrinkles in the skin surface than a second type of tourniquet cuff (Zimmer) with or without two layers of commonly available cast padding, and a third type (Kidde) with padding. With the second type of cuff, using cast padding reduced skin wrinkling compared to applying the same cuff on unprotected skin. In view of the survey, clinical literature, and results of this study, a guideline for use of pediatric tourniquets is proposed.