A Clinical Risk Case Study- Tourniquet Injury
Co-written by The TMLEP Clinical Risk and Patient Safety Publishing Group with Mr Ben Rudge MBBS FRCS, Consultant Orthopaedic Surgeon
Tourniquet use is commonplace in surgery to create a bloodless field and facilitate the procedure. Unfortunately, tourniquet related injuries can sometimes occur ranging from temporary skin abrasions or bruising, through to full thickness burns and skin loss.
There are many factors that can contribute to a tourniquet injury, including but not limited to:
Inappropriate tourniquet size
Excessive duration of tourniquet inflation
Excessive pressure of tourniquet inflation.
Problems with the padding (e.g. a cotton wool type padding underneath to protect the skin)
Inadequate fluid protection - antiseptic fluid ingress under the tourniquet can contribute to injury and can be prevented with specific devices such as rubber shields.
Despite there being several variables contributing to tourniquet injury, currently, there are no standardised guidelines for their application or use. The lack of guidance perhaps contributes to a wide variation in practice amongst the many different team members who may apply the tourniquet such as ODPs, scrub nurses, surgical consultants, trainees, students and anaesthetists.
Furthermore, there is all too often a lack of documentation in patient notes regarding the detail of how a tourniquet was used during a procedure. It is commonplace to only document duration and pressure of inflation in the clinical notes, therefore, making any investigation into the causes of a tourniquet injury challenging, if not impossible.
A 45-year-old woman was admitted for surgery having suffered a mid-foot injury. She underwent surgical fixation during which a thigh tourniquet was inflated.
It was noted in recovery that the patient had a skin contusion on her posterior thigh at the site where the tourniquet had been applied.
The contusion deteriorated rapidly, and the subsequent wound required regular dressings including treatment for an MRSA colonisation. Full healing took a total of 6 months leaving an unsightly scar and the need for camouflage make up.
Our Independent Clinical Findings
As mentioned above the causes of a tourniquet injury are multifactorial.
In this case the tourniquet was documented to have been inflated to a pressure of 315mmHg for 1hr and 40mins. The pressure and duration of inflation was deemed acceptable here as, whilst there are no clear guidelines, common practice is to inflate the tourniquet to around 300mmHg for up to 2 hours (and beyond this there is also a wide variation in practice).
Unfortunately, there was no documentation of how, or indeed if, the tourniquet had been padded or whether any steps had been taken to prevent ingress of antiseptic fluid beneath it.
The surgeon explained that their usual practice was to use an appropriately sized tourniquet that was well padded with wool incorporating a bespoke splashguard to prevent ingress of skin preparation fluid underneath. Such standards were unfortunately not demonstrated in the medical records here and, moreover, the occurrence of the injury suggested that these standards may not have been maintained in this case.
Our independent review found that although the tourniquet pressure and duration of application was acceptable, it was not possible to demonstrate adequate use of padding or fluid shielding, therefore, the tourniquet application demonstrated substandard clinical practice, causative of the harm sustained.
How to prevent recurrence and improve patient safety
Agreed clinical guidelines are needed to reduce the incidence of tourniquet related injuries occurring.
We would, however, suggest that immediate steps be taken with regards to documentation such that when a tourniquet is used, attention is given to clearly recording the following in the medical records:
The Tourniquet application site
The use and type of padding beneath the tourniquet
The steps taken around shielding for fluid protection
The duration of tourniquet application
The level of tourniquet pressure
If there is clear documentation of exemplary practice i.e. it is documented that the defendant has taken all reasonable steps to avoid an injury occurring, this is a valuable defence.
Beyond improving clinical practice such information would be of great benefit when it comes to investigating and potentially defending these costly claims.
This case highlights an area where healthcare professionals are leaving themselves vulnerable to claims when these devastating injuries occur, perhaps due to no clear guidelines being available. Nonetheless, it is evident when independently reviewing cases that if clinicians follow clear steps when applying a tourniquet (as set out in this article) and such steps are recorded clearly in the medical records, the subsequent opportunity for healthcare litigation to arise will be substantially reduced for tourniquet related injuries.
Important Notice: This article is intended to raise awareness to clinical risk issues in an effort to reduce incidence recurrence and improve patient safety. This is not intended to be relied upon as advice. Facts have been altered to ensure this case is non-identifiable, albeit clinical learning points remain applicable. To request an independent clinical review, please contact email@example.com or call +44 (0)203 355 9796.
The TMLEP Clinical Risk and Patient Safety Publishing Group with Mr Ben Rudge MBBS FRCS, Consultant Orthopaedic Surgeon. (2018). A Clinical Risk Case Study- Tourniquet Injury. TMLEP Clinical Risk Case Studies. 1 (4), 1.