Tourniquet Issues

   Many times, a quality nerve block could be considered a ‘failure’ or the anesthetic plan has to be altered because the use of or the exact position of the tourniquet was not considered. You KNEW the case warranted a nerve block or a continuous nerve block, and you knew the appropriate nerves to block to cover the ENTIRE surgical procedure, and the block had had PLENTY of time to set up…..and you were even ready WAY ahead of the scheduled start time. And then you walk in the O.R., and you see someone applying the tourniquet…way up there!  “Well, if it starts to bother them, just slip in an LMA, I guess.” [nonmember]…

 

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 Even with a solid nerve block, after about an hour, the blood pressure and heart  rate will begin to ‘drift up’ in an anesthetized patient due to the intense stimulation of ischemic pain. An alert or sedated patient will react much sooner to an unanesthetized area under the tourniquet. Whether converting to a general anesthetic is still a  possible option or treatment of vital signs is what needs to occur, a change in the anesthetic plan can be perceived as a lack of appropriate planning, and mismanagement of tourniquet pain may cause you to lose the outcome optimization you had in mind (or even cause you to worsen your usual turnover time). If I am planning to use only a nerve block  for a case that may have a widely variable time frame, I always inform the surgeon (and the patient, of course) that we may convert to a general anesthetic for ‘this particular patient’ and do everything possible to make sure it does so in a slick and seamless manner if needed. In either event, relying too heavily on opioids (especially on long-acting opioids) can burn unnecessary bridges at the end of the case. It can lead to those awkward moments that happen when the crew is looking at you after they’ve finished cleaning the floor, and the patient is still not breathing. Tourniquet pain won’t evaporate completely the moment it is released, but a great deal of that stimulation will be gone at the end of the case, and that can result in apnea or significant hypopnea. Focus more at these times on increasing the concentration of volatile anesthetic and adding smaller doses of fentanyl or beta blockers to tide them over.

     Make sure your PACU RN’s know how to distinguish residual tourniquet pain (diffuse throughout the limb, sometimes worse at the surgical site) from a failed or ‘partial’ nerve block and don’t inadvertently cause over-sedation and a really long PACU time by the same mistake. This sort of information should be emphasized in the ‘hand-off’ but could also likely be detected by reviewing the anesthetic record before giving bigger doses of long-acting opioids.

     The best way around all of this is to remember the likelihood of tourniquet use, especially in orthopedics. Be prepared for the position of the tourniquet, know the typical pattern of tourniquet pain and make sure everyone knows the appropriate plan to deal with it. See Tourniquet Issues #2 for more ideas about tourniquets.

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