AORN Guideline in Focus: Pneumatic Tourniquet Safety

Pneumatic tourniquets are commonly used in perioperative practice to improve visibility of the surgical field and reduce intraoperative blood loss. AORN’s Guideline for Pneumatic Tourniquet Safety, approved in April 2025, provides evidence-based recommendations to help perioperative teams optimize the use of tourniquets while minimizing the risk of patient harm. Improper selection, application, or monitoring can increase the risk of serious complications, including nerve injury, compartment syndrome, chemical burns, and postoperative pain.

The guideline outlines best practices for pneumatic tourniquet safety, from preoperative patient assessment and cuff selection to determining safe inflation pressures and monitoring during and after use. Key recommendations include:

• Preoperative assessment and risk identification (1.3)
• Tourniquet selection and sizing (2.1)
• Determining safe inflation pressures (4.1)
• Monitoring during inflation (5.4)
• Safe methods for deflation (6.1)
• Postoperative monitoring and communication (6.5, 6.9)

What You Should Consider Before Tourniquet Application?

A thorough preoperative assessment is essential to identify patient-specific risk factors for complications such as vascular issues, impaired skin integrity, or a history of tourniquet-related injuries (1.3).

Collaborate with the surgeon and anesthesia professional to develop a perioperative care plan that minimizes risks and includes strategies for safe tourniquet use (1.4).

How to Select and Apply the Tourniquet

Select a tourniquet cuff that is appropriately sized and shaped for the patient’s limb, taking into account the procedure and manufacturer’s instructions for use (2.1).

Use protective padding around the cuff site to minimize pressure-related injury (3.3) and apply a physical barrier between the cuff and the surgical site to prevent fluid accumulation and contamination of the cuff (3.5).

Determining Safe Inflation Pressure

Set the inflation pressure based on the individual patient’s characteristics instead of using a standard value (4.1).

Best Practices for Monitoring During Inflation

Keep inflation time as short as possible to minimize the potential for ischemic injury (5.1).

Continuously monitor the patient for signs of complications such as skin changes, circulatory issues, or pain while the tourniquet is inflated (5.4).

Safe Tourniquet Deflation

Determine the best tourniquet deflation method—gradual, intermittent, or sudden—based on the patient’s hemodynamic status, the type of procedure, and the anesthesia plan (6.1).

Once deflated, assess the patient’s vital signs (6.5), including temperature (6.6), and monitor for pain or signs of complications related to tourniquet use (6.8).

Maintaining High Standards for Safety

Provide ongoing education and verify the competency of perioperative team members on the safe use of pneumatic tourniquets and assessment for related complications (8.1).

Pneumatic Tourniquet Safety Guideline References

• Altin R, Yesil M, Ozcan O, Karaca C, Sen S, Firat F. An investigation into the cellular-level adverse effects of tourniquet use on the infrapatellar fat pad in primary total knee arthroplasty: a prospective randomized study. Acta Orthop Traumatol Turc. 2023;57(5):283–288. [IB]  
• Xu X, Wang C, Song Q, Mou Z, Dong Y. Tourniquet use benefits to reduce intraoperative blood loss in patients receiving total knee arthroplasty for osteoarthritis: an updated meta-analysis with trial sequential analysis. J Orthop Surg (Hong Kong). 2023;31(2):10225536231191607. [IA]
• Cai DF, Fan QH, Zhong HH, Peng S, Song H. The effects of tourniquet use on blood loss in primary total knee arthroplasty for patients with osteoarthritis: a meta-analysis. J Orthop Surg Res. 2019;14(1):348. [IA]
• Salari P, Balato  G, Cavallo G, Strigelli V, Meccariello A, Baldini A. The staged use of tourniquet does not influence the fast-track recovery after total knee arthroplasty: a prospective randomized study. Arch Orthop Trauma Surg. 2024;144(11):4677–4684. [IB] 
• Goel R, Rondon AJ, Sydnor K et al. Tourniquet use does not affect functional outcomes or pain after total knee arthroplasty: a prospective, double-blinded, randomized controlled trial. J Bone Joint Surg Am. 2019;101(20):1821–1828. [IA]
• Kasem SA, Bassiouny AAE, Rashwan DAE, Bahr MH. Minimal inflation tourniquet pressure using induced hypotension with limb occlusion pressure determination or arterial occlusion pressure estimation in upper limb surgery: a randomized double-blinded comparative study. Anesth Pain Med. 2020;10(2):e102124. [IA]