Moving to a new type of sterile and single use tourniquet
for orthopaedic surgery
Author: Mr G P de Kiewiet, MBchB, FRCS, RCPS, FRCSEd, FRCSEd(Orth)
Introduction
Tourniquets are widely used in orthopaedic limb surgery in order to provide the surgeon with optimised visual capacity by creating a bloodless field followed by arterial occlusion proximal to the surgical site. We identified a number of potential patient risks in using the current methods, so, in order to reduce these risks, we felt the need to improve on our current bloodless surgery techniques. To help establish a mechanism for improving on our current methods, we evaluated a new type of sterile exsanguinating tourniquet called the S-MART, and found this, amongst other things, to reduce the preparation and tourniquet time, reduce cross infection risk and provide a first rate bloodless field in elective paediatric surgery.
In order to show the benefits of using this new device we need to consider the current methods of achieving exsanguination (removal of blood from a limb) and arterial occlusion, and the problems that can often arise with these methods.
How the current tourniquet method works
Historically tourniquets have been used routinely at Sunderland Royal Hospital in the Paediatric theatres. Development and implementation of tourniquet technology in limb surgery was established due to the need for a clear and bloodless field during the procedure. This is particularly relevant and important in paediatric cases as the type of surgery to which the tourniquet is applied, which is often intricate enough in adult cases, can increase in intricacy due to the smaller size of the patients’ limbs. Further more the need to reduce blood loss is always important.
Traditionally, our method of achieving arterial occlusion was to apply a special, smaller, paediatric pressure cuff to the exsanguinated limb as a tourniquet. Exsanguination itself can be accomplished through various methods; limb elevation, Reece-Davis, Esmarch being the most popular techniques. At Sunderland Royal Infirmary, the preparation of the patient’s limb generally takes place in the anaesthetic room prior to transfer into theatre.
This helps reduce the theatre time of the procedure but also leaves us with some more significant logistical problems that we felt could be avoided through the use of a different technique.
Disadvantages of the current method
In the paediatric cases, we usually start the patient’s preparation by administering the anaesthetic. After the anaesthetic has been applied and the first preparatory stage of exsanguination has been performed, the pressure cuff must be inflated in order to occlude arterial flow and prevent blood from flowing back into the limb before surgery. We usually use tube or Reece Davis in order to achieve limb exsanguination and while this is being carried out, the pressure cuff is being prepared with its necessary padding and drapes, in order to provide as comfortable and aseptic field as possible. In most cases the patients are asleep on application and it is vital that all the necessary steps are taken to avoid the chances of skin burns from the fabric of the pressure cuff and contamination with the surgical prep fluids. Once the patient is padded and the surgical site protected from the chances of cross infection, inflation of the cuff concludes the initial preparation. After these activities, the limb is disinfected in the normal way prior to the first incision being made
In this instance, the patient is under anaesthesia for the duration of the preparation. The same surgical and logistical result can be achieved by preparing the cuff before anaesthetic, in order to reduce the anaesthetic time. However, this results in an increase in the tourniquet time and means that the patient would feel the discomfort of the tourniquet for a short time while the anaesthetic was being administered and may also increase the risk of damage to internal structures. This is something we wanted to try and avoid, particularly in paediatrics. Application prior to anaesthesia will also increase the anxiety levels in this group of patients.
Avoiding increased anaesthetic and tourniquet time
Unfortunately, by using these methods, either the anaesthetic, or tourniquet time are extended, neither of which is particularly desirable but is, unfortunately, unavoidable when using a pressure cuff as a tourniquet. However, with the S-MART™ exsanguinating tourniquet we have found an innovative yet simple solution that allows the tourniquet time to be reduced whilst avoiding an extension to the anaesthetic time.
In short, the traditional, separate methods of exsanguination, arterial occlusion and application of a sterile stockinette to the limb are encapsulated in the one device, which means that all of the required preparatory steps are achieved in one simple movement. However, adding to this is the fact that the device is sterile so it can be applied immediately after the disinfecting process. What this means is that the siting of the S-MART™ can be the last step before incision. It is by using this principle that we have been able to reduce the need for additional resource in the anaesthetic room and to reduce the tourniquet time whilst leaving the duration of anaesthesia unaffected.
Effective exsanguination and arterial occlusion
This device is relatively new in the UK and was discovered by members of our theatre nursing team whilst attending the AfPP Congress is Harrogate last year. The information with regards to the use of the device was brought back to Sunderland Royal Infirmary and we felt that this could be exactly the solution that we had been looking for.
Part of the initial attraction of the S-MART™ is its simple but innovative approach in finding a solution to the problems we face when using traditional tourniquet methods.
The device itself is comprised of a tensile silicone ring – the elasticity of which varies by device type depending on what range of systolic pressures you wish to occlude - over which is rolled a long fabric stockinette. Into the stockinette is also rolled a set of straps with pull handles attached to the end. The idea is that fingers or toes of the patient are placed into the central hole of the device and, when in position, the straps are pulled, and the S-MART™ is rolled up the limb to the desired location. This process stretches the silicone ring, applying increasing pressure during lateral movement along the limb taper as the circumference of the limb increases. Blood is therefore squeezed from the limb to the point where the S-MART™ is sited. When the placement site is reached, the movement stops, resulting in a constant pressure, which ensures arterial occlusion.
As well as being sterile, the S-MART™ is much narrower than normal pressure cuffs which means that it can be placed closer to the surgical site without increasing the risk of cross infection. This is particularly useful when performing surgery on the elbow as the amount of room between the elbow and shoulder for pressure cuff placement is limited. It also means that there is less ischemic tissue as a lower volume of internal limb structure is under pressure with a narrower cuff.
Evaluation of new technique
Having considered the viability of this device for our paediatric cases, we first used the S-MART™ in November 2005. The decision was taken to evaluate in order to address some of the concerns that we had with pressure cuffs including the potential for abrasive skin burns and poor bloodless fields, although other benefits soon became apparent.
On the day that it was first evaluated, we had three paediatric cases. First, there was a 7 year-old boy who required a wrist tendon transfer, followed by an 11 year-old girl having a diagnostic knee arthroscopy and, finally, a 3 year-old boy for a flexor tenotomy of the foot.
There was, of course, quite a variation in limb size over the three cases but the manufacturers of the S-MART™ have developed a method of ensuring that there is an appropriate device available to cover all but the most extreme limb sizes. Traditionally, the same pressure cuff would be used on all limb sizes but with the S-MART™ you can choose the most appropriate device by measuring the circumference of the limb where the device is to be sited and then reading off supplied tables.
Which size of device you choose depends on the limb circumference and there are 4 sizes to choose from that range from S-MART Small (14-28cm circumference) to the S-MART™ XL (50-90cm circumference). In between there is the S-MART™ 40 (20-40cm circumference) and the S-MART™ 60 (30-60cm circumference). They also come in a range of colours which signify the range of systolic pressures that the S-MART will occlude so it is important to understand the systolic pressure of the patient before choosing the device. The necessary charts were supplied to us by the manufacturer and plenty of advice provided in order to ensure that the correct system was identified before use.
Appropriate device selection
As well as the device selection charts, we were also provided with tables which allowed us to understand the pressure at the limb surface for any given device. This figure is equivalent to the readout provided by the pressure cuff machine.
So, the circumference of the limb at the desired tourniquet site and the patient’s systolic pressure are measured so that the right system can be identified. The device arrives sterile and is double wrapped for theatre, the packaging clearly showing the size and pressure capability of each individual system. The S-MART™ is handled using the normal theatre handling techniques to ensure aseptic delivery into the surgical field. Inside the pack there is a plastic “cutting card”. This is required at the end of the surgery to aid the removal the S-MART™ and so needs to be retained.
Because the S-MART™ is sterile, the anaesthetic can be applied and the disinfecting preparations carried out before device placement. When preparations are complete and the first incision awaits, the S-MART™ should be applied.
In order to place the S-MART™, we cut off the closed end of the stockinette for the hand and foot procedures. For the arthroscopy case, access was gained through the stockinette at the surgical site. To remove the S-MART™, the plastic cutting card was placed proximal to the device and the device was rolled over the leading edge of the card. The S-MART™ ring was then cut with a scalpel and the device removed, allowing blood to flow back into the limb.
Excellent bloodless field
All three of the cases for which we evaluated the device were remarkably successful. After the S-MART™ was rolled on to the limb of the first case and the first incision was made it was immediately apparent that the S-MART™ was going to provide us with exactly what we needed. Simply a visual examination of the skin surface was enough to show that exsanguination had been effective and, if that wasn’t enough, the absence of any bleeding after the first incision confirmed it. Using the device was easy and placement was last minute, reducing tourniquet time but, most importantly of all, the surgical field was completely bloodless throughout, leaving a clear view which is ultimately important in delicate cases such as these.
Other areas of benefit
There was a lot of curiosity in the product when it arrived in theatre from all theatre personnel. It is an intriguing device at first sight, partly due to the various colours that represent the pressure range. We used two S-MART™ Small devices (pink), aimed specifically at paediatrics, on the tendon transfer and flexor tenotomy. These are applicable with systolic pressures up to 130mmHg. The arthroscopy case utilised the red device. This was an S-MART™ 40 applicable to medium systolic pressure ranges. The anaesthetists were particularly interested to find out how the S-MART™ coped with variations in systolic pressure as, at first glance, the devices seem to be quite similar. They were happy with the solution and the advice provided in choosing the appropriate system. We even had an ODP begin preparations in theatre for the placement of a sterile stockinette for the diagnostic arthroscopy. He was particularly surprised and pleased to hear that this would not be necessary as the S-MART™ applies a stockinette automatically during placement. He was subsequently able to turn his attention to other tasks which further demonstrated how the S-MART™ can also improve current use of theatre resources.
In all, the experience for the staff and the patients has been very positive and after such a resounding success in the initial evaluation phase we chose to continue the use of the product. To date, we have performed 20 operations ranging from flexor tenotomy to osteotomies and tendon transfers on patients with an age range of 14 years (Max 16, Min 2) and in all cases a clear and bloodless field has enabled us to perform the surgery with the accuracy and confidence required to ensure a positive clinical outcome.
Limitation of use
The one disadvantage of this technique is that if you remove the cuff to achieve haemostasis through the operation, you are unable then to re-inflate the cuff should this be desirable with certain procedures. Furthermore use of the cuff over fractured bones or open wounds would be undesirable and its main use therefore lies within the elective paediatric surgical field.
The future of S-MART™
With S-MART™, we now feel that we have found a suitable alternative to the pressure cuffs in paediatric and young adult cases and, as such, will no longer be commissioning the use of the pressure cuff tourniquets in these procedures. The S-MART™ is a very simple device which has provided us with a more effective tourniquet solution with regards to all aspects including ease of use, flexibility, time, resource and, of course, infection control and quality of the bloodless field, which needs to be second to none. Our intention is continue the use of the device and there may be future opportunities to expand the benefits of the device into other areas in the hospital such as day care.
Achieving Better Outcomes
Without Altering Your Surgical Technique
Authors: Mr Philip Sell, Consultant Orthopaedic Surgeon, University Hospitals of Leicester and Queens Medical Centre, Nottingham
Prof Gordon Waddell, Orthopaedic Surgery
Dr Alison McGregor, Physiotherapy London
Prof Kim Burton, Ergonomics Huddersfield
Clinical outcomes of surgery for disc herniation and spinal stenosis are variable. Various surveys show that post-operative management is not uniform. Many different health care professionals interact with patients and their beliefs and views may influence patients and the expectations they have of recovery after surgery. It would appear that spinal surgeons and their patients are uncertain about what best to do post-operatively.
In all care of the patient three principal streams of action should be considered: Pre-hospital care, In-hospital care and rehabilitation. The last may well be the critical factor that determines the final status of patient recovery.
We all recognise that consent is extremely important. The principals and the specifics of surgical procedure are also critical. What is less clear are the different post operative regimes that surgeons use.
If at the time of listing for surgery and at pre-operative assessment quality information is given to patients regarding rehabilitation this has the potential for maximising the final recovery from a spinal disorder. Avoiding mixed messages and using best evidence are a common part of every day spinal practice. Patients relatives are often concerned and by involving them in the process with consistent and clear messages about return to activity ‘mixed messages’ can be overcome.
It can be time consuming repeating the same information to similar patient groups on a regular basis and the provision of quality information sources means that ‘face to face ‘ patient time is spent on the important issues for both parties.
The ‘curabo’ effect has recently been documented and reveals the importance of attitude and motivation, in both patient and surgeon.
Post-operative management after lumbar surgery is inconsistent leading to uncertainty amongst surgeons and patients reactivation and return to work. To address this uncertainty about post-operative restrictions, a patient centred evidenced-based booklet on post-operative management after lumbar discectomy or un-instrumented decompression has been developed.
This was achieved through a systematic literature search which produced a best-evidence synthesis of information and advice on post-operative restrictions, activation, rehabilitation, and expectations about outcomes. The literature review found little evidence for post-operative activity restrictions, and a strong case for an early active approach to post-operative management. The booklet was built around key messages derived from the evidence statements extracted from the literature review and aimed to reduce uncertainty, promote positive beliefs, encourage early reactivation, and provide practical advice on self-management.
Following a focused literature review, a patient-centred, evidence-based booklet was developed. The aim was to guide post-operative management and facilitate recovery. Initial peer and patient evaluations were encouraging and the booklet [Your back operation. www.tso.co.uk/bookshop] is currently factored into a trial investigating the post-operative management of spinal patients.
To date, 80 patients have been recruited into a randomised trial to receive the booklet. At six months post-surgery all of these patients are requested to complete a questionnaire on the booklet. This questionnaire contained forced-choice questions on readability, style, information level, believability, length, content and helpfulness.
Feedback is very positive. The average overall rating of the booklet was 8.6/10. Over 80% found it easy to read, interesting, and of appropriate length. Over 80% also stated they had learnt new and helpful information. All subjects stated that they would recommend the booklet to a friend, and the majority stated that they frequently referred to the booklet. The predominant messages received and understood by the patients were related to the safe benefits of early activation and return to normal activities.
It remains to be seen if the results of the study show that the booklet influences final outcome. Certainly early results show that spinal surgery patients appreciate evidence-based information in booklet form, and suggest that this booklet may be an important adjunct to post-operative management of spinal patients. In practical terms it is a well received communication that intuitively assists in patient care at very low cost.
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