Proper exsanguinator and tourniquet use poorly understood

By Sarah Guy

Operating theater personnel have a poor understanding of appropriate exsanguinator and tourniquet use, show research results from a hospital in Ireland.

None of the staff members - including porters, nurses, senior house officers, registrars, and consultants - scored 50% or higher on a questionnaire designed to determine understanding among those responsible for appropriate application and use of these surgical instruments.

Furthermore, 18 of 20 instruments examined showed evidence of positive culture growths, including coagulase-negative Staphylococcus, Staphylococcus aureus, and Acinetobacter, reports the research team.

Both exsanguinators and tourniquets are used in the majority of orthopedics cases to prevent limbs being subjected to high pressures, and to control blood circulation to an extremity, explain Zubin Daruwalla and colleagues from Tallaght Hospital in Dublin.

"If applied correctly, [the devices] provide an inherent benefit of a bloodless surgical field to the operator, but their use is not without complications" the team writes in The Surgeon, highlighting that the tools may represent a potential vector of infection between patients.

A total of 74 operating theater personnel completed a questionnaire compiled using guidelines from the Association of periOperative Registered Nurses, including such questions as: "where approximately on a limb should the cuff be positioned?"

The overall mean score was 30.9%, with the highest score (48.4%) achieved by an operating nurse in the seventh year of clinical practice, and the second highest score (46.1%) achieved by a specialist registrar in their third year of training.

A senior porter with more than 10 years' experience gained the lowest score of 9.4%, which is alarming, write Daruwalla et al, considering that in their institution and others like it, porters are the personnel who exsanguinate limbs and apply tourniquets, while the surgeon is ultimately responsible for any consequences.

At the end of a single day operating, swabs from all of the exsanguinators (n=10) and eight of 10 tourniquets showed pathogenic growths after microbiologic culture to determine sterility.

The team compared the pathogens identified on the devices with those found in wound site sepsis in a cohort of 24 infected ankle fracture wounds, and found that the majority of bacteria responsible were also coagulase-negative - namely, S. epidermidis.

Such bacteria are a common source of prosthetic joint infection, note Daruwalla and co-workers, and may require prolonged antimicrobial treatment and/or repeat surgery "which affects patient outcomes, bed availability and hospital costs."

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