Some tourniquet cuffs are designed and manufactured to be reusable in multiple surgeries and their reuse is authorized by the manufacturer. Limited guidance on cleaning, reprocessing, testing and evaluation of reusable cuffs may be provided by the manufacturer, but there is a general need for improvement and more guidance for users.
Other types of tourniquet cuffs are designed manufactured to be safely used as single-use, sterile disposable tourniquet cuffs, and their reprocessing and reuse is not authorized by the manufacturer.
Some general recommendations about tourniquet cuff safety are given in the AORN Recommended Practices for Use of the Pneumatic Tourniquet.  Published literature provides still further guidance, eg [2-9].
The current (2009) AORN Recommended Practices (RPs) are in need of updating regarding tourniquet cuff safety, tourniquet cuff reuse and tourniquet cuff reprocessing. For example:
1. For single-use disposable tourniquet cuffs, the RPs do not indicate the hazards to the patient that may be associated with unauthorized reprocessing and inadequate testing of disposable cuffs after reprocessing and prior to any reuse.
2. For reusable tourniquet cuffs, the RPs do not provide recommendations on what type of testing of reusable cuffs should be performed after cleaning and before reuse.
3. For both reusable and single-use disposable tourniquet cuffs, the RPs do not recommend how the results of cuff testing and inspection should be documented and evaluated after cleaning and before any reuse.
4. In current RPs such as those excerpted below, it is not clear which recommendations are meant to include tourniquet cuffs as well as tourniquet instruments.
Relevant excerpts from the current (2009) AORN RPs are given below:
Recommended Practice II: The pneumatic tourniquet and its accessories should be inspected, tested and maintained according to manufacturers’ written instructions.
6. Before each use, the entire tourniquet system should be checked. The cuff and tubing should be inspected for cracks, leaks, and the security of the closure mechanism. Unintentional pressure loss can result from loose tubing connectors, deteriorated tubing, or cuff bladder leaks, and may result in patient injury.
Recommended Practice XIV: The pneumatic tourniquet and accessories should be cleaned after each use.
4. Single-use cuffs should be discarded in an appropriate receptacle.
Recommended Practice XVII: Policies and procedures for pneumatic tourniquets should be developed, reviewed periodically, revised as necessary, and readily available in the practice setting.
1. Policies and procedures for the pneumatic tourniquet should include, but are not limited to:
– safety features required on pneumatic tourniquets;
– equipment maintenance programs; supplemental safety monitors required;
– equipment checks before initial use;
– reporting and impounding malfunctioning equipment;
– preoperative, intraoperative, and postoperative patient assessments;
– responsibility for cuff application;
– precautions during use;
– reporting of injuries;
– potential adverse events;
– care and cleaning of the tourniquet after use; and
2. The frequency, method, and criteria for pneumatic tourniquet testing should be established according to manufacturers’ written instructions. A pneumatic tourniquet management program assists in identifying equipment problems that may have adverse effects on patient safety.
Recommendations Regarding Future Guidelines
The following recommendations for guidelines, based on published literature (eg [2-9]) and manufacturers’ recommendations as available, as well as the current AORN RPs , would better reflect current practices and would improve tourniquet cuff safety and effectiveness.
1. For patient safety and for facility risk management purposes, establishment of a tourniquet cuff testing program is recommended, so that each cuff is thoroughly tested according to a written protocol after each use, and prior to the next use, with the results thoroughly documented. (Some modern tourniquet instruments allow this to be done automatically.)
2. For each reusable tourniquet cuff, it is recommended that the cuff have a unique identifier, that the number of reuse cycles be recorded, and that the cuff be thoroughly tested on a regular basis by qualified personnel, with results documented and evaluated.
3. For reusable cuffs used in certain procedures, eg IVRA or Bier block anesthesia, it is further recommended that consideration be given to replacing the cuff after a maximum number of reuse cycles is reached, to reduce the risk of cuff failure and patient injuries during use.
4. It is recommended that the tourniquet cuff testing protocol be established in accordance with the recommendations of the original manufacturer of the cuff. At a minimum, a cuff testing protocol should include:
(a) a leak test, including inflating the cuff to a maximum pressure recommended by the manufacturer for a period of time, with the cuff wrapped around a test mandrel or laid flat,
(b) a fastener integrity test, to assure that the fasteners are not degraded to the point of being unsafe at the maximum pressure specified by the manufacturer,
(c) a physical inspection of the cuff to detect blockages of the pneumatic passageway in any portion of the inflatable bladder or tubing due to reprocessing damage or fluid entry,
(d) a visual inspection of the cuff to detect damage or deterioration, including: any warping of stiffener due to inappropriate reprocessing; discolouration or contamination of the cuff surface; damage or deterioration of the cuff connector or inflatable portion; and
(e) written documentation and evaluation of the test results before a decision is made regarding cuff reuse.
Results of hospital-based inspections and testing of reusable (not disposable) tourniquet cuffs, identifying patient hazards and risks, have been published in the AORN Journal and elsewhere, eg [2-9].
Reusable tourniquet cuffs that are specifically intended by their manufacturers to be used in multiple surgeries generally are accompanied by some instructions on how to inspect, clean and test such cuffs between uses. Often, the instructions are limited and no information is provided on cuff testing programs, on cuff testing protocols and on the documentation and evaluation of cuff testing results.
Disposable tourniquet cuffs are generally supplied as sterile, single-use products by manufacturers. Some facilities and individuals reuse disposable cuffs. However, there are no established guidelines at present to assure patient safety during reuse.
Hazards and risks are associated with unauthorized reprocessing and inadequate testing of reprocessed disposable cuffs.  Reprocessing efforts typically involve saving rather than discarding a disposable tourniquet cuff after surgery, visually examining the cuff to identify any obvious deterioration that might suggest reprocessing is not appropriate, attempting to remove any blood and other surgical debris by washing the cuffs with water combined with any of a variety of detergents or other cleaning liquids, disinfecting in some instances with various disinfecting agents, and in some cases conducting functional tests of the cuff, often using non-standard protocols and results that are neither documented nor evaluated relative to established criteria.
Some of these disposable cuffs may be reused as non-sterile cuffs after only cleaning, or after only cleaning and disinfection, with no functional testing and with no attempt to re-sterilize the cuff. In other situations, cleaned cuffs may be re-packaged and then re-sterilized by exposure to a sterilization agent within a sterilization process that may be different from that determined by the original manufacturer to be safe and effective. Reprocessing of disposable tourniquet cuffs, with or without re-sterilization, may be carried out within hospitals or surgery centers or by third-party reprocessors, and the quality and methods of reprocessing are highly variable.
Reprocessing of disposable tourniquet cuffs may result in hazards for the surgical patients on whom such cuffs are subsequently used. One such hazard arises from deterioration of cuff materials due to the use of any of a variety of chemical or physical agents that are attendant with the reprocessing, cleaning, disinfection and possible re-sterilizing processes. For example, exposure of a cuff to liquids during cleaning and disinfection may allow the liquids to enter and partially or completely block the pneumatic passageway within the port and inflatable portion of the cuff. If the cuff is re-sterilized as part of the reprocessing, any water remaining within the pneumatic passageway after cleaning may subsequently react chemically with ethylene oxide, a sterilizing agent commonly used in reprocessing, to form ethylene glycol, a sticky substance that may completely or partially block the pneumatic passageway.
Repeated exposure of cuffs containing flexible thermoplastic materials to an elevated temperature during drying after cleaning or disinfection with liquids, or during re-sterilization, may soften thermoplastic materials and components, increasing the likelihood of hazardous deformation of some components, including: substantial deformation of the thermoplastic stiffener included in some cuffs that may impair the application of pressure by such a cuff to an underlying limb upon subsequent use in surgery; partial or complete blockages of the pneumatic passageways within ports or thermoplastic connectors of some cuffs; and weakening of the retention force of typical thermoplastic barb-type port connectors so that such connectors cannot establish or reliably maintain a gas-tight passageway between the tourniquet cuff and tourniquet instrument upon reuse. In general, repeated reuse of a disposable tourniquet cuff beyond the limit of usage specified by the manufacturer, including exposure to cleaning and disinfection agents and processes not anticipated by the manufacturer if reused as non-sterile cuffs, and including exposure to re-sterilization agents and processes if reused as sterile cuffs, may progressively increase the hazards for the surgical patients on whom the cuff is used.
References and Citations
1. http://www.aorn.org/PracticeResources/AORNStandardsAndRecommendedPractices/EDocuments/ AORN, Recommended Practices for the Use of the Pneumatic Tourniquet, 2009.
2. www.tourniquets.org – McEwen JA, Educational website focused on surgical tourniquets, and related tourniquets for military and emergency applications, including tourniquet safety and usage.
5. McEwen JA, Inkpen K. “Tourniquet safety: Preventing skin injuries.” The Surgical Technologist, 24(8) (2002): 6-15.
6. McEwen JA, Inkpen K, Younger A.”Thigh tourniquet safety.” The Surgical Technologist, 24(7) (2002): 9-18.
7. Tredwell SJ, Wilmink M, Inkpen K, McEwen JA. “Pediatric tourniquets: Analysis of cuff/limb interface and guidelines for use.” Journal of Pediatric Orthopaedics, 21(5) (2001): 671-6.
8. McEwen JA. “Complications of and improvements in pneumatic tourniquets used in surgery.” Medical Instrumentation, 15(4) (1981): 253-7.
9. Noordin et al. “Surgical Tourniquets in Orthopaedics” Journal of Bone and Joint Surgery, 91 (2009): 2958-2967. http://www.jbjs.org/
10. McEwen JA et al, “Integrated tourniquet system.” US Pat. App. No. 20100211096, Aug 2010. http://patft.uspto.gov/
11. McEwen JA and Jameson M. “Surgical tourniquet cuff for limiting usage to improve safety.” US Pat No. 7,955,352, June 2011. http://patft.uspto.gov/
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