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Anesth Analg 2003;97:1529-1532
© 2003 International Anesthesia Research Society

GENERAL ARTICLES

Controlled Hypotension and Minimal Inflation Pressure: A New Approach for Pneumatic Tourniquet Application in Upper Limb Surgery

Bahattin Tuncali, MD*, Ayse Karci, MD*, Abdul Kadir Bacakoglu, MD{dagger}, Binnur Erdalkiran Tuncali, MD*, and Ahmet Ekin, MD{dagger}

*Department of Anesthesiology and Reanimation, Dokuz Eylul University, and the {dagger}Department of Orthopaedics and Traumatology-Division of Hand Surgery, Dokuz Eylul University, Izmir, Turkey

Address correspondence to Dr. Bahattin Tuncali, Huzur mah, Sumbul sok, No:42/11 Narlidere, Izmir, Turkey. Address email to tuncalibin{at}ttnet.net.tr


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 References
 
Minimal inflation pressures are recommended for limb surgery to eliminate complications attributable to high inflation pressures with the pneumatic tourniquets. We applied controlled hypotension and a minimal inflation pressure (CHAMIP) technique to provide a bloodless surgical field. Thirty-six patients scheduled for upper extremity surgery were randomized equally to receive either normotensive anesthesia and conventional inflation pressures or controlled hypotension (systolic arterial blood pressure of 80–100 mm Hg and mean arterial blood pressure >60 mm Hg) and minimum inflation pressures. Anesthesia was induced with propofol IV bolus and remifentanil IV continuous infusion and maintained with propofol and remifentanil IV continuous infusion. To determine the minimal inflation pressure, the digital plethysmograph was applied to the second finger at the side of the operation and the tourniquet was inflated slowly until the arterial pulsations disappeared on the oscilloscope. A bloodless surgical field was obtained in almost all patients, even though systolic arterial blood pressures (100–138 mm Hg versus 80–100 mm Hg) and applied tourniquet inflation pressures (270 mm Hg versus 110–140 mm Hg) were significantly lower in the hypotensive group. No complications associated with controlled hypotension were encountered. In conclusion, CHAMIP may be a safe and reliable method for upper extremity surgery performed with pneumatic tourniquets.

IMPLICATIONS: Pneumatic tourniquets are associated with adverse effects resulting from high inflation pressures. Therefore, minimal inflation pressures are recommended in extremity surgery. To reach real minimal inflation pressure the patient’s blood pressure must be reduced. We used controlled hypotension with remifentanil and propofol to reach minimal inflation pressures.


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 References
 
Pneumatic tourniquets are often used to reduce blood loss and to provide optimal operating conditions during extremity surgery (1). However, compression of the tissues under a tourniquet is associated with soft tissue injuries involving muscle, artery, skin, and, most importantly, peripheral nerves (2). To minimize the risk of complications from excessive inflation pressures, the use of wider tourniquet cuffs and minimal inflation pressures, as determined by Doppler stethoscope or digital plethysmography, have been suggested (3). These recommendations were based on studies performed with normotensive, but not with hypotensive, patients.

A controlled hypotension technique has often been used in anesthesia practice during cerebral aneurysm surgery, orthopedic operations such as total hip and knee arthroplasty, resection of head and neck tumors, ear surgery, and operation of patients who refuse blood transfusion because of their religious beliefs, to reduce blood loss and the need for blood transfusion (4–8). Remifentanil combined with propofol conveniently provide induced hypotension with no need for additional use of potent hypotensive drugs (9). However, use of a controlled hypotension technique to reach minimal tourniquet inflation pressures during upper extremity surgery has not been described.

The aims of this study were to apply controlled hypotension with a propofol-remifentanil combination to reach minimal tourniquet inflation pressures and to compare the effectiveness of this technique with conventional tourniquet inflation pressures in patients scheduled for upper extremity surgery under general anesthesia.


   Methods
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 Abstract
 Introduction
 Methods
Results
 Discussion
 References
 
After the Hospitals Ethic Committee approval, informed consent was obtained from 36 adult, ASA physical status I–II patients scheduled for upper extremity surgery. Exclusion criteria included cerebrovascular disease, hypertension, renal and/or hepatic insufficiency, peripheral claudication, severe anemia, and hypovolemia.

Patients were randomized to receive normotensive anesthesia and conventional inflation pressures (Group 1, n = 18) or controlled hypotension and minimal inflation pressures (CHAMIP) (Group 2, n = 18). Random numbers were put into sealed envelopes and opened before each anesthesia induction. The patients were not premedicated. On arrival at the operating suite an 18-gauge IV catheter was inserted in the arm that was not operated. Standard monitoring, including invasive arterial blood pressure monitoring, was used. The radial artery was cannulated on the side opposite that of the surgical procedure. A pneumatic tourniquet was applied to the arm with a layer of "soft-roll" under wrap. The width of the tourniquet cuff was 11 cm in all patients.

Anesthesia was induced with propofol (1.5–2.5 mg/ kg IV bolus) and remifentanil (0.5 µg · kg-1 · min-1 continuous IV infusion), and endotracheal intubation was facilitated by use of rocuronium (0.8–1.2 mg/kg IV). After induction of anesthesia, a 20- gauge catheter was placed in the radial artery for invasive blood pressure monitoring. Anesthesia was maintained with propofol (4–5 mg · kg-1 · h-1) and remifentanil (0.3–1 µg · kg-1 · min-1) continuous infusion to provide normotension in Group 1 and to provide hypotension (systolic arterial blood pressure of 80–100 mm Hg and mean arterial blood pressure >60 mm Hg) in Group 2. The lungs were ventilated with 40% O2/60% N2O to maintain an ETCO2 at approximately 30 mm Hg.

In Group 2, to determine the minimal inflation pressure, the digital plethysmograph was applied to the second finger at the side of the operation and the tourniquet was inflated slowly until the arterial pulsations disappeared on the oscilloscope before the actual study was commenced. This pressure was recorded as occlusion pressure and the tourniquet was deflated. In all patients the limb was exsanguinated with an elastic bandage before tourniquet inflation. In Group 1, the pneumatic tourniquet was inflated with conventional pressures (250–300 mm Hg) that are routinely used in our hospital; in Group 2 minimal inflation pressure (occlusion pressure +20 mm Hg) was applied.

The gender and age of the patients, circumference of the upper extremity, tourniquet application times, systolic arterial blood pressures, and tourniquet inflation pressures were recorded at 0, 5, 15, 30, 60, and 120 min. After the operation the surgeon who was blinded to groups completed a questionnaire in which he rated the performance of the tourniquet as satisfactory, less than satisfactory, or unsatisfactory at the beginning, middle, and end of the surgical procedure.

After the surgical procedure was completed all anesthetics were discontinued and patients were tracheally extubated and transferred to the recovery room. All patients were examined on the day after surgery for signs of any complications, such as skin damage, nerve palsies, or vascular occlusion, that could be associated with the use of a tourniquet. The patients were asked whether or not they felt pain, burning, coldness, numbness, or paraesthesia on their hands by an investigator. The patients and the person asking the questions were blinded as to the groups.

Data were analyzed using Wilcoxon’s signed-rank test with repeated measures within groups. Mann-Whitney U-test was used for nonparametric data between groups. A value of P < 0.05 was considered to be statistically significant.


   Results
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 Abstract
 Introduction
 Methods
 Results
Discussion
 References
 
Thirty-six patients were included in the study. All patients received general anesthesia for the operation. The demographic characteristics (age, gender, circumference of the extremity) and the mean tourniquet application times were not statistically different between the groups (Table 1).


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  		Table 1. Demographic Data
 
The surgical procedures were tendon, artery, nerve repair, open reduction, and internal fixation, finger amputation, tendon transfer, debridement, and neurolysis on the upper extremity.

During the tourniquet period, systolic arterial blood pressures were 100–138 mm Hg in Group 1 and 80–100 mm Hg in Group 2; whereas tourniquet inflation pressures were 270 mm Hg in Group 1 versus 110–140 mm Hg in Group 2. Systolic arterial blood pressures and applied tourniquet pressures were not different at 0, 5, 15, 30, and 120 minutes within groups. However both systolic arterial blood pressures and tourniquet pressures were statistically different (P < 0.001) between groups at all stages (Fig. 1).



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  		Figure 1. Systolic arterial blood pressures (SAP) and applied tourniquet pressures in each group. In Group 2 Controlled hypotension and minimal inflation pressure technique allowed significantly lower systolic arterial blood pressures and tourniquet inflation pressures at all stages of the tourniquet period compared with Group 1. Results are mean ± SD. Tourniquet pressures were 270 mm Hg in Group 1 and 118.2 ± 7.2 mm Hg (mean ± SD) in Group 2 (range, 110–140 mm Hg), P < 0.0001.

 
The performance of the tourniquets was assessed as satisfactory in all stages of the procedure in 18 patients in Group 1 and in 17 patients in Group 2. Only one case was rated as "less than satisfactory" in the middle stage of the operation in Group 2 by the surgeon, though inflation pressures were significantly lower in Group 2 compared with Group 1 (P < 0.0001) (Table 2).


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  		Table 2. Surgeon’s Opinion About the Performance of the Tourniquets and Tourniquet Inflation Pressures
 
In Group 1, three patients complained of paresthesia and numbness in the hand and fingers on the side of the operation at the second postoperative hour, lasting 24 h, whereas none of the patients in Group 2 experienced such complaints. This difference was not statistically significant.


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
References
 
Approximately 100 years have elapsed since Cushing (1904) introduced the pneumatic tourniquet, but the safe limits for duration of tourniquet ischemia and inflation pressure are still being discussed (1–3,9). Spiegel and Lewin (1945) recommended 450 mm Hg and Mc Elvenny (1945) used 350 mm Hg for the arm tourniquet. Sanders (1979) suggested 70 mm Hg greater than the preoperative systolic blood pressure and a similar value was suggested by Adams (1976). It is generally accepted that a safe pressure for an upper limb tourniquet is 250–300 mm Hg irrespective of the patient’s blood pressure (Stewart, 1975; Edmonson, 1980) (10).

Because pneumatic tourniquets have been associated with temporary or permanent damage to soft tissues, blood vessels, and nerves it would seem logical to limit the tourniquet pressure to a level that will provide hemostasis yet avoid unnecessary pressure on soft tissue structures. However, care must also be taken to avoid the passive congestion and increased bleeding that result from underinflation of the tourniquet (11). To reach such optimal pressures the broadest possible tourniquet cuffs are recommended. This will allow the use of smaller inflation pressures, which will lead to a reduction in the incidence of complications associated with the use of a tourniquet (1,10). In this study we used the same (11 cm) tourniquet cuff in all patients and there were no significant differences among patients’ arm circumferences, so the results were only related to systolic arterial blood pressures.

To determine the minimal inflation pressure for the upper limb Levy et al. (12) and Reid at al. (13), using Doppler technique, recommended 202.3 ± 34.2 and 190 mm Hg respectively. Estebe et al. (1) and Hagenouw et al. (14) used pulse oximetry to confirm the absence of the arterial pulse to determine the minimum inflation pressure. Newman and Muirhead (10) used systolic arterial pressure + 35 mm Hg with broad cuffs and obtained satisfactory results with 166 ± 19.6 mm Hg inflation pressures for the arm tourniquet. In 2002, the Association of Operating Room Nurses (15) recommended systolic arterial blood pressure +50–75 mm Hg for the arm tourniquet to obtain a bloodless field.

It seems rational to relate the tourniquet pressure to the patient’s blood pressure. In the literature, all studies recommending "minimal inflation pressure" were performed with normotensive patients. Thus, these pressures cannot be accepted as minimal inflation pressures. It is possible to reach smaller pressures than these minimal inflation pressures by decreasing the systolic arterial blood pressure of the patients. To decrease the systolic arterial blood pressures, we used a controlled hypotension technique. Remifentanil, a short acting µ-opioid receptor agonist, is currently used with propofol. Compared with fentanyl and alfentanil, remifentanil appears to offer superior intraoperative hemodynamic stability and maintains intact cerebral blood flow reactivity. However, it appears to provoke moderate to mild hypotension (9). Thus, a propofol and remifentanil combination was used as a continuous infusion with N2O to induce hypotension. With this technique, mean arterial blood pressures were easily and successfully maintained at >=60 mm Hg to protect cerebral perfusion pressure. No complications were encountered during the intraoperative or postoperative period. These results were similar to previous reports.

Thus, using the CHAMIP technique we reached inflation pressures smaller than that recommended in the literature. With this technique minimal inflation pressures ranged between 110–140 mm Hg (mean, 118.2 mm Hg); moreover, we obtained a bloodless surgical field in almost all cases. As 250–300 mm Hg tourniquet inflation pressures have been used routinely for upper extremity surgery in our hospital, Group 1 tourniquet inflation pressures were chosen as 270 mm Hg. Similarly high tourniquet inflation pressures, such as 350–400 mm Hg, are routinely used in lower extremity surgery in our hospital. Using the same technique we have a similar study in lower extremity in progress.

Using a questionnaire to evaluate the surgical field had been described previously (10). In this study the surgeon was satisfied with the performance of the tourniquet in almost all cases. Only one case was rated as "less than satisfactory" in the middle stage of the operation in Group 2. In this case, oozing started after the first hour, lasted approximately 15 minutes and disappeared spontaneously. The surgeon was notified that this oozing did not adversely affect the surgical procedure or its duration.

Paralysis after use of a tourniquet during surgery is a well-recognized complication (16). Direct pressure caused by the pneumatic cuff is regarded as the main cause of nerve lesions; ischemic injury may also play a part (17). Tourniquet paralysis nearly always resolves spontaneously. However, the patient is unable to work for a considerable length of time, and recovery from operation is clearly impeded (18). In our study 3 patients in Group 1 complained of paresthesia in the hand and fingers that may have been related to high inflation pressures. Because of the small number of patients in both groups, causative factors for these signs could not to be determined.

In conclusion, to reach real minimal inflation pressures with the pneumatic tourniquet we suggest the CHAMIP technique may be an excellent choice.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 

  1. Estebe JP, Le Naorues A, Chemaly L, Ecoffey C. Tourniquet pain in a volunteer study: effect of changes in cuff width and pressure. Anaesthesia 2000; 55: 21–6.[ISI][Medline]
  2. McLaren AC, Rorabeck CH. The pressure distribution under tourniquets. J Bone Joint Surg Am 1985; 67: 433–8.[Abstract/Free Full Text]
  3. Kam PCA, Kavanaugh R, Yoong FFY. The arterial tourniquet: pathophysiological consequences and anaesthetic implications. Anaesthesia 2001; 56: 534–45.[ISI][Medline]
  4. Van Aken H, Miller ED. Deliberate hypotension. In: Miller RD, ed. Anesthesia. New York: Churchill Livingstone 2000; 1470–90.
  5. Henriksen L, Thorshauge C, Harmsen A, Chistensen P. Controlled hypotension with sodium nitroprusside: effects on cerebral blood flow and cerebral venous blood gases in patients operated for cerebral aneurysms. Acta Anaesthesiol Scand 1983; 27: 62–7.[ISI][Medline]
  6. Vazeery AK, Lunde O. Controlled hypotension in hip joint surgery. Acta Ortop Scand 1979; 50: 433–41.
  7. Bembridge JL, Moss E, Grummitt M, Noble J. Comparison of propofol with enflurane during hypotensive anaesthesia for middle ear surgery. Br J Anaesth 1993; 71: 895–7.[Abstract/Free Full Text]
  8. Toivonen J, Kuikka P, Kaukinen S. Effects of deliberate hypotension induced by labetalol with isoflurane on neuropsychological function. Acta Anaesthesiol Scand 1993; 37: 7–11.[ISI][Medline]
  9. Degoute CS, Ray MJ, Manchon M, et al. Remifentanil and controlled hypotension: comparison with nitroprusside or esmolol during tympanoplasty. Can J Anaesth 2001; 48: 20–7.[Abstract/Free Full Text]
  10. Newman RJ, Muirhead A. A safe and effective low pressure tourniquet. J Bone Joint Surg Br 1986; 68: 625–8.
  11. Shaw JA, Murray DG. The relationship between tourniquet pressure and underlying soft-tissue pressure in the thigh. J Bone Joint Surg Am 1982; 64: 1148–52.[Abstract/Free Full Text]
  12. Levy O, David Y, Heim M, et al. Minimal tourniquet pressure to maintain arterial closure in upper limb surgery. J Hand Surg [Br] 1993; 18: 204–6.[Medline]
  13. Reid HS, Camp RA, Jacob WH. Tourniquet hemostasis: a clinical study. Clin Orthop 1983; 177: 230–4.
  14. Hagenouw RPM, Bridenbaugh PO, Egmond JV, Stuebing R. Tourniquet pain: a volunteer study. Anesth Analg 1986; 65: 1175–80.[Abstract/Free Full Text]
  15. Association of Operating Room Nurses. Recommended practices for use of the pneumatic tourniquet. AORN J 2002; 75: 379–86.[Medline]
  16. On AY, Özdemir O, Aksit R. Tourniquet paralysis after primary nerve repair. Am J Phys Med Rehabil 2000; 79: 298–300.[ISI][Medline]
  17. Larsen UT, Hommelgaard P. Pneumatic tourniquet paralysis following intravenous regional analgesia. Anaesthesia 1987; 42: 526–8.[ISI][Medline]
  18. Aho K, Sainio K, Kianta M, Varpanen E. Pneumatic tourniquet paralysis. J Bone Joint Surg Br 1983; 65: 441–3.
Accepted for publication May 23, 2003.




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This Article
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Right arrow Articles by Tuncali, B.
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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press