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Pediatric tourniquets: analysis of cuff and limb interface, current practice, and guidelines for use
S J Tredwell1, M Wilmink, K Inkpen
1Jack Bell Research Centre, Vancouver, British Columbia, Canada. tredwell@interchange.ubc.ca
Insights
Pediatric tourniquet use lacks clear guidelines. A study found a specific pediatric tourniquet cuff and sleeve minimized skin damage, unlike other options, leading to proposed usage recommendations.
Area of Science:
- Pediatric Surgery
- Orthopaedics
- Biomedical Engineering
Background:
- Current pediatric tourniquet application lacks standardized guidelines for pressure settings, cuff selection, and limb protection.
- Surveys indicate frequent use of tourniquets in pediatric orthopaedics, with reported complications including skin, nerve, and muscle injuries.
- Existing literature offers limited data on optimal pediatric tourniquet cuff and padding configurations for minimizing tissue damage.
Purpose of the Study:
- To evaluate different tourniquet cuff and padding combinations for their effectiveness in protecting pediatric limb skin.
- To compare the degree of skin wrinkling and potential for injury under various pediatric tourniquet setups.
- To propose evidence-based guidelines for pediatric tourniquet use.
Main Methods:
- A survey of pediatric orthopaedic surgeons was conducted to assess current tourniquet practices and complication rates.
- A digital measurement technique was employed to quantify skin surface deformation (wrinkles) under four different tourniquet cuff/padding configurations.
- Trials were performed on healthy child volunteers using pediatric-specific and standard tourniquet cuffs with and without padding.
Main Results:
- The Delfi pediatric tourniquet cuff with its matching limb-protection sleeve demonstrated significantly fewer and less severe skin wrinkles compared to Zimmer and Kidde cuffs.
- Using cast padding with the Zimmer cuff reduced skin wrinkling compared to using the cuff alone on unprotected skin.
- Skin damage was a common complication (21/67), with nerve and muscle injuries also reported.
Conclusions:
- The Delfi pediatric tourniquet system appears superior in minimizing skin surface damage during pediatric surgical procedures.
- Proper selection of tourniquet cuffs and padding is crucial for preventing complications in pediatric limb surgery.
- The study findings support the development of standardized guidelines for pediatric tourniquet application to enhance patient safety.
Abstract:
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.
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