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"Thigh Tourniquet Safety: Preventing Skin Injuries." James A. McEwen Ph.D., P.Eng., Kevin Inkpen M.A.Sc. The Surgical Technologist 34(8) (Aug 2002): 6-15.

"Pediatric Tourniquets: Analysis of cuff/limb interface, current practice, and guideline for use" Tredwell SJ, Wilmink M, Inkpen K, and McEwen J: Journal of Pediatric Orthopedics (in press September/ October 2001, Issue 21 Volume 5).

Abstract: There are few clear guidelines on the proper use of tourniquets in pediatric surgery, and 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. We could find only one published study specifically addressing pediatric cuff pressures, and no studies that show what types of cuff and/or padding create the smoothest skin surface under the cuff. Of 46 pediatric orthopedic surgeons we surveyed, 44 use a tourniquet 4.6 times per week on average and 2 have discontinued their use due to complications. To set cuff pressure, 13/44 use a standard value, 14/44 base pressure on age, extremity, and size, and 17/44 base cuff pressure on blood pressure. 34/44 use skin protection under the cuff yet 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, we compared the maximum wrinkle heights and the sums of all wrinkle heights in the skin surface under 4 different cuff/padding configurations. In a total of 44 trials on the upper arms and thighs of 2 healthy child volunteers, one type of pediatric cuff with 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 2 layers cast padding, and a third type (Kidde) with padding (P < 0.01). With the second type of cuff, using cast padding reduced skin wrinkling compared to applying the same cuff on unprotected skin (P < 0.05). In view of the survey, clinical literature, and results of this study, a guideline for use of pediatric tourniquets is proposed.

Key words: tourniquet, survey, guideline, injury, hazard, pressure.