580559 research-article2015
JHS0010.1177/1753193415580559Journal of Hand Surgery (European Volume)Short report letter
JHS(E)
Short report letter
The Journal of Hand Surgery (European Volume) XXE(X) 1–2 jhs.sagepub.com
What is the maximum safe tourniquet time in elective upper limb surgery? Dear Sir, Upper limb tourniquets are used widely and are typically very safe (Odinsson and Finsen, 2006; Drolet et al., 2014). For adults, the recommended maximal tourniquet time vary widely, with 1 hour 30 minutes–2 hours being the most widely accepted (Odinsson and Finsen, 2006; Drolet et al., 2014). Yet Flatt (1972) reported that it was safe to use an upper limb tourniquet for up to 2 hours 45 minutes. The guidance to surgeons may satisfy the precautionary principle, but not be evidence based. The aim of this study was to assess local symptoms and any complications of upper limb tourniquet use for over 2 hours in a cohort of elective hand surgical patients. All patients were included who had a tourniquet applied for more than 2 hours over a 5-year period 1999–2004. The vast majority of the patients operated in this period had tourniquet times of 03:00
29 21 16 9 6
0 4 (19%) 2 (13%) 1 (11%) 1 (17%)
0 2 (10%) 4 (25%) 2 (22%) 3 (50%)
0 1 (5%) 1 (6%) 1 (11%) 1 (17%)
Downloaded from jhs.sagepub.com at Freie Universitaet Berlin on May 11, 2015
2
The Journal of Hand Surgery (Eur)
no immediate post-operative pain or distal paraesthesia. In the other patient, it was noticed after 8 weeks, again following multiple procedures for the rheumatoid hand. The tourniquet time was 3 hours 5 minutes; this patient reported initial distal paraesthesia that resolved within 24 hours. Follow-up questionnaires were sent to 71 patients for whom addresses were known. One patient had died. A total of 61 patients responded (86%). The minimum post-operative time to questionnaire was 10 months. Four patients reported distal pain symptoms unconnected to the site of the tourniquet. Three patients reported distal paraesthesia: two of these had paraesthesia immediately post-operatively that had resolved completely; the third had persistent paraesthesia that seemed primarily related to their underlying rheumatoid arthritis (RA) rather than the tourniquet, but may have been due to the long tourniquet time (>2 hours 45 minutes). No patient reported any other complications not previously noted; none reported symptoms suggestive of compartment syndrome. Tourniquet use is typically very safe (Odinsson and Finsen, 2006). Most tourniquet complications are associated with either the duration of ischaemia or the pressure generated beneath the cuff. Sometimes prolonged tourniquet use is needed to address a complication during surgery or to undertake multiple procedures. The absolute safe limit of tourniquet duration has not been established. Overall our findings reflect those of Flatt (1972), who showed that 60 patients with a tourniquet duration of between 2 hours 45 minutes had no post-operative complications. This is important as many authorities quote time limits for upper limb tourniquet use of 1 hour 30 minutes or more reasonably 2 hours. This study and Flatt’s work appear to show that tourniquet use can be safely extended to well beyond 2 hours. The majority of our patients had tourniquet times between 2 hours 45 minutes, and even in these patients there
was a trend to more short-term symptoms. These may simply reflect responses to more surgery but may also be due to swelling and soft tissue injury from longer tourniquet times. There were only 11 patients with tourniquet times >2 hours 45 minutes and these patients had an even stronger trend towards more short-term symptoms, and the only patient with possible long term symptoms from tourniquet use was in this group. The data more strongly support the use of an arm tourniquet up to, than beyond 2 hours 45 minutes. The ability to use a tourniquet for >2 hours gives greater flexibility to surgeons planning complex operations or addressing complications during operations by allowing longer tourniquet use. It should also help resist spurious medico-legal claims based solely on prolonged tourniquet times. Nonetheless we would strongly advocate minimizing tourniquet use as we do not know whether there may be subtle physiological changes that should be minimized for patient benefit. Conflict of interest None declared.
References Drolet BC, Okhah Z, Phillips BZ et al. Evidence for safe tourniquet use in 500 consecutive upper extremity procedures. Hand. 2014, 9: 494–8. Flatt AE. Tourniquet time in hand surgery. Arch Surg. 1972, 104: 190–2. Odinsson A, Finsen V. Tourniquet use and its complications in Norway. J Bone Joint Surg Br. 2006, 88: 1090–2.
N. Sawant and G. E. B. Giddins Royal United Hospital, Bath, UK Corresponding author: [email protected]
© The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav doi: 10.1177/1753193415580559 available online at http://jhs.sagepub.com
Downloaded from jhs.sagepub.com at Freie Universitaet Berlin on May 11, 2015
JHS0010.1177/1753193415580559Journal of Hand Surgery (European Volume)Short report letter
JHS(E)
Short report letter
The Journal of Hand Surgery (European Volume) XXE(X) 1–2 jhs.sagepub.com
What is the maximum safe tourniquet time in elective upper limb surgery? Dear Sir, Upper limb tourniquets are used widely and are typically very safe (Odinsson and Finsen, 2006; Drolet et al., 2014). For adults, the recommended maximal tourniquet time vary widely, with 1 hour 30 minutes–2 hours being the most widely accepted (Odinsson and Finsen, 2006; Drolet et al., 2014). Yet Flatt (1972) reported that it was safe to use an upper limb tourniquet for up to 2 hours 45 minutes. The guidance to surgeons may satisfy the precautionary principle, but not be evidence based. The aim of this study was to assess local symptoms and any complications of upper limb tourniquet use for over 2 hours in a cohort of elective hand surgical patients. All patients were included who had a tourniquet applied for more than 2 hours over a 5-year period 1999–2004. The vast majority of the patients operated in this period had tourniquet times of 03:00
29 21 16 9 6
0 4 (19%) 2 (13%) 1 (11%) 1 (17%)
0 2 (10%) 4 (25%) 2 (22%) 3 (50%)
0 1 (5%) 1 (6%) 1 (11%) 1 (17%)
Downloaded from jhs.sagepub.com at Freie Universitaet Berlin on May 11, 2015
2
The Journal of Hand Surgery (Eur)
no immediate post-operative pain or distal paraesthesia. In the other patient, it was noticed after 8 weeks, again following multiple procedures for the rheumatoid hand. The tourniquet time was 3 hours 5 minutes; this patient reported initial distal paraesthesia that resolved within 24 hours. Follow-up questionnaires were sent to 71 patients for whom addresses were known. One patient had died. A total of 61 patients responded (86%). The minimum post-operative time to questionnaire was 10 months. Four patients reported distal pain symptoms unconnected to the site of the tourniquet. Three patients reported distal paraesthesia: two of these had paraesthesia immediately post-operatively that had resolved completely; the third had persistent paraesthesia that seemed primarily related to their underlying rheumatoid arthritis (RA) rather than the tourniquet, but may have been due to the long tourniquet time (>2 hours 45 minutes). No patient reported any other complications not previously noted; none reported symptoms suggestive of compartment syndrome. Tourniquet use is typically very safe (Odinsson and Finsen, 2006). Most tourniquet complications are associated with either the duration of ischaemia or the pressure generated beneath the cuff. Sometimes prolonged tourniquet use is needed to address a complication during surgery or to undertake multiple procedures. The absolute safe limit of tourniquet duration has not been established. Overall our findings reflect those of Flatt (1972), who showed that 60 patients with a tourniquet duration of between 2 hours 45 minutes had no post-operative complications. This is important as many authorities quote time limits for upper limb tourniquet use of 1 hour 30 minutes or more reasonably 2 hours. This study and Flatt’s work appear to show that tourniquet use can be safely extended to well beyond 2 hours. The majority of our patients had tourniquet times between 2 hours 45 minutes, and even in these patients there
was a trend to more short-term symptoms. These may simply reflect responses to more surgery but may also be due to swelling and soft tissue injury from longer tourniquet times. There were only 11 patients with tourniquet times >2 hours 45 minutes and these patients had an even stronger trend towards more short-term symptoms, and the only patient with possible long term symptoms from tourniquet use was in this group. The data more strongly support the use of an arm tourniquet up to, than beyond 2 hours 45 minutes. The ability to use a tourniquet for >2 hours gives greater flexibility to surgeons planning complex operations or addressing complications during operations by allowing longer tourniquet use. It should also help resist spurious medico-legal claims based solely on prolonged tourniquet times. Nonetheless we would strongly advocate minimizing tourniquet use as we do not know whether there may be subtle physiological changes that should be minimized for patient benefit. Conflict of interest None declared.
References Drolet BC, Okhah Z, Phillips BZ et al. Evidence for safe tourniquet use in 500 consecutive upper extremity procedures. Hand. 2014, 9: 494–8. Flatt AE. Tourniquet time in hand surgery. Arch Surg. 1972, 104: 190–2. Odinsson A, Finsen V. Tourniquet use and its complications in Norway. J Bone Joint Surg Br. 2006, 88: 1090–2.
N. Sawant and G. E. B. Giddins Royal United Hospital, Bath, UK Corresponding author: [email protected]
© The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav doi: 10.1177/1753193415580559 available online at http://jhs.sagepub.com
Downloaded from jhs.sagepub.com at Freie Universitaet Berlin on May 11, 2015
