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Summary of the best evidence for the safe use of pneumatic tourniquet in limb surgery

BMC Surgery volume 24, Article number: 281 (2024) Cite this article

Abstract

Purpose

To retrieve, evaluate, and summarize the best available evidence regarding the safe use of pneumatic tourniquet in patients undergoing Limb surgery, providing guidance for preoperative assessment, operation methods and precautions, complication prevention and treatment in clinical practice.

Methods

Using the PIPOST tool, we formulated an evidence-based question, conducted searches in relevant Chinese and international databases and websites for clinical decisions, guidelines, evidence summaries, systematic reviews, and expert consensus on the use of limb surgical tourniquets. The search was limited to literature published until September 30, 2023. Quality assessment and evidence extraction were performed on eligible documents.

Results

This study included a total of 13 articles, including 2 clinical decision-making articles, 3 guidelines, 5 expert consensus articles, 1 standard and 2 systematic reviews. A total of 34 best pieces of evidence recommendations were summarized across 10 aspects, including indications and contraindications for the use of pneumatic tourniquets, preoperative evaluation of operators, selection and placement of tourniquet cuffs, tourniquet inflation, monitoring during inflation, tourniquet deflation, common complications and prevention, equipment safety, documentation, and training and education.

Conclusion

The best evidence summarized in this study can provide reference for clinical medical staff to safely use pneumatic tourniquets, but in clinical practice, targeted selection and application of evidence should be combined with specific situations to improve the safety and hemostatic effect of pneumatic tourniquet use.

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Introduction

The pneumatic tourniquet (abbreviated as tourniquet) is a commonly used hemostatic device in clinical limb surgery. It blocks blood flow to the surgical site of the limb, reduces bleeding, creates a “bloodless” field of view, and improves surgical safety and efficiency. Although the handling of a tourniquet is relatively simple, there still exists a phenomenon of non-standard operation. Such as improper cuff selection, loosely applied cuff, high/low cuff pressure and prolonged inflation [1, 2], as well as solutions used for operative preparation underneath the tourniquet and remain there during tourniquet inflation [3], and improper cuff deflation [4] et al. This can lead to adverse outcomes for patients postoperatively, including Increased bleeding, nerve and soft tissue injuries, thromboembolism, increased pain, burn, extended recovery times, and decreased muscle strength [5,6,7]. The correct management of indications, contraindications, and potential risk factors associated with the use of limb surgical tourniquets, along with a focus on the details of tourniquet application, is paramount for ensuring the safe utilization of limb surgical tourniquets in limb surgery. At present, domestic and foreign research mostly focuses on the effectiveness of tourniquet use [8, 9], the impact of inflation pressure settings, and protective measures on complications [10, 11]. However, there remains controversy within relevant guidelines and expert consensus regarding tourniquet pressure settings, duration of inflation, and lack of systematic and scientific guidance for the entire process of intraoperative tourniquet application. Therefore, this study employs an evidence-based approach to systematically retrieve, summarize, and integrate the best available evidence from China and other countries worldwide concerning the safe use of tourniquets in limb surgery. Intended to establish clinical guidelines for the safe and effective use of pneumatic tourniquets. This includes defining clear indications and contraindications, optimizing preoperative assessments, ensuring the appropriate selection of cuffs, and setting accurate pressure and duration parameters. Additionally, the study aims to highlight the importance of monitoring during tourniquet use and document records, et al. to minimize intraoperative bleeding and reduce postoperative complications, thereby enhancing overall surgical safety.

Materials and methods

Problem formulation

Using the PIPOST tool developed by the Evidence-Based Nursing Center at Fudan University in China [12, 13], we formulated an evidence-based nursing question as follows: P (population): patients undergoing limb surgery who use pneumatic tourniquets during the procedure. I (intervention): the safe use of pneumatic tourniquets, including indications and contraindications, preoperative assessment, tourniquet and placement selection, exsanguination, pressure and time settings, inflation and deflation, inflation monitoring, complications prevention, instrument maintenance and upkeep. P (professional): surgeons, anesthesiologists, and circulating nurses. O (outcome): the effectiveness and complications associated with pneumatic tourniquet use, such as surgical duration, intraoperative bleeding volume, total blood loss, pain, thromboembolism, nerve injuries, and skin pressure injuries. S (setting): operating room. T (type of evidence): clinical decisions, evidence summaries, systematic reviews, guidelines, and expert consensus.

Search approach and strategy

Following the “6S” evidence model [14], searches were conducted as follows: (1) Clinical Decision Support Systems: BMJ Best Practice, UpToDate. (2) Guideline Websites and Professional Association Websites: National Guideline Clearinghouse (NGC), Registered Nurses Association of Ontario (RNAO), Scottish Intercollegiate Guidelines Network (SIGN), National Institute for Health and Care Excellence (NICE), New Zealand Guidelines Group, Canadian Medical Association Clinical Practice Guidelines Database, Association of perioperative Registered Nurses (AORN), Association of Surgical Technologists (AST), British Orthopaedic Association(BOA), Chinese Nursing Association Operating Room Professional Committee, MedSci China Guideline Network, China Clinical Guidelines Library (CGC). (3) Databases: Nursing Consult, Joanna Briggs Institute (JBI) Evidence-Based Healthcare Database, DynaMed, Trip, Campbell, Elsevier, Cochrane Library, EBSCO, CINAHL, Embase, PubMed, OVID, China National Knowledge Infrastructure (CNKI), China Biomedical Literature Database (CBM), VIP Database, Wanfang Database. The English search terms include “pneumatic tourniquet, * tourniquet, air pressure hemostasis instrument, vascular occlusion and vascular block. The search query in English databases like PubMed, using a combination of controlled vocabulary and free-text terms, is as follows: (“tourniquet”[Mesh] OR “*tourniquet”[Ti/Ab] OR “air pressure hemostasis instrument”[Ti/Ab] OR “vascular occlusion”[Ti/Ab] OR “vascular block”[Ti/Ab]) AND (“Indications”[Ti/Ab] OR “contraindications”[Mesh] OR “preoperative Assessment”[Ti/Ab] OR “cuff selection and position”[Ti/Ab] OR “Exsanguinate the extremity” [Ti/Ab] OR “pressure setting” [Ti/Ab] OR “time setting” [Ti/Ab] OR “inflation” [Ti/Ab] OR “inflation monitoring” [Ti/Ab] OR “deflation”[Ti/Ab] OR “complications prevention” [Ti/Ab] OR “maintenance” [Ti/Ab]). The search period covered the time from the establishment of the databases until September 30, 2023.

Inclusion and exclusion criteria for literature

Inclusion Criteria: (1) Studies involving patients undergoing limb surgery who use pneumatic tourniquets during the procedure. (2) Studies focusing on measures related to the safe use of pneumatic tourniquets and prevention of complications. (3) Study types including clinical decisions, systematic reviews, evidence summaries, guidelines, and expert consensus. (4) Studies available in both Chinese and English.

Exclusion Criteria: (1) Studies involving the use of pneumatic tourniquets for pre-hospital emergency hemostasis in patients. (2) Incomplete or inaccessible information, duplicate publications. (3) Interpretations or translated versions of foreign guidelines, non-latest or abbreviated versions of guidelines. (4) Studies judged to be of low quality according to the literature quality assessment criteria.

Literature quality assessment

Four researchers independently assessed the included guidelines, and two researchers independently assessed the quality of expert consensus, standard and systematic reviews. In cases of conflicting opinions, resolution was achieved through negotiation or the involvement of a third researcher. All four researchers have received systematic training in evidence-based methodology. When conflicting conclusions arise from different sources of evidence, selection is guided by the principles of prioritizing high-quality evidence, evidence-based findings, and the most recently published authoritative literature. The Criteria for Literature Quality Assessment as follows:

  1. (1)

    The quality of guidelines related to the safe use of pneumatic tourniquets was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) system [15]. This assessment system consists of six domains (23 items) and two overall assessment items. Each item is scored from “completely not met” to “completely met”, with scores ranging from 1 to 7. The sum of scores for all items in each domain is calculated, and this score is then standardized as a percentage of the maximum possible score for that domain. The standardized scores determines the quality of the guideline, and this study excludes Level C literature.

  2. (2)

    The original literature that traces clinical decisions and evidence summaries is initially assessed based on the type of original research. For the identified literature, quality assessments are conducted using the appropriate assessment tools, including the JBI Critical Appraisal Checklist for Case Series and Systematic Reviews [9].

  3. (3)

    Expert consensus and standards are assessed using the JBI Expert Consensus Assessment Criteria (2017 version) [16], which comprises six items and is rated as “yes”, “no”, “unclear”, or “undetermined”.

  4. (4)

    Systematic reviews are evaluated for quality using the AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews) criteria (2017 version) [16], consisting of 16 items. Ratings are categorized as “yes”, “partial yes”, or “no” to grade the quality of the systematic review as “high quality”, “moderate quality”, “low quality”, or “critically low quality”.

Evidence extraction, integration, and summarization

Two researchers independently conducted evidence extraction focusing on key aspects of pneumatic tourniquet use. The extracted information included publication date, study type, source of evidence, evidence topic, and specific content. The process of translating, extracting, and integrating evidence involved the participation of all researchers. Principles of evidence integration: (1) When evidence content is consistent, prioritize evidence that is concise, clear, and professionally oriented. (2) When evidence content complements each other, merge the evidence into logically structured statements. (3) When there are differences in evidence content, prioritize evidence based on the principles of evidence-based, high-quality, authoritative, and recently published evidence. In this study, four researchers were divided into two groups to evaluate the original literature included in the evidence based on the JBI Evidence Pre-grading and Recommendation Grading System (2014 version) [16]. In cases of disagreement, all four members discussed and made a decision. The evidence was categorized from “highest level” to “lowest level” based on the type of original research and further classified into levels 1–5. Recommendations were divided into strong recommendations (Grade A) and weak recommendations (Grade B) based on evidence applicability, feasibility, effectiveness, and clinical significance.

Results

General characteristics of included literature

This study included a total of 13 articles, comprising 2 clinical decision articles [17, 18], 3 guidelines [19,20,21], 5 expert consensus papers [22,23,24,25,26], 1 standard [27] and 2 systematic reviews [9, 28]. The literature selection process is illustrated in Fig. 1, and the general characteristics of the included literature are presented in Table 1.

Fig. 1
figure 1

Literature screening workflow

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Table 1 General characteristics of included literature (n = 13)
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Literature quality assessment results

Quality assessment results for clinical decision-making

In this study, a total of 2 clinical decision articles were included, and tracing their original literature resulted in 1 cohort study [29] and 2 systematic reviews [30, 31]. Regarding the study by Olivecrona et al. [29], except for the item ‘Whether the description of the absence of outcome measures in the study population at exposure or at the beginning of the study is unclear’, which was rated as ‘unclear’, all other items were rated as ‘yes’. Therefore, this literature was of high quality and was included. As for the studies by Alcelik et al. [30] and Zhang et al. [31], the quality assessment results are presented in Table 2.

Table 2 AMSTAR 2 scores of included systematic reviews
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Quality assessment results of the guidelines

This study included a total of 3 guidelines [19,20,21]. The standardized percentage scores for each domain and the overall assessment opinions are presented in Table 3.

Table 3 Methodological quality assessment of included guidelines
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Quality assessment results for expert consensus and standard

This study included a total of 5 expert consensus [22,23,24,25,26] and 1 standard [27] articles. The quality of these articles was high, with all criteria evaluated as “yes”, and they were included in the analysis.

Quality assessment results of systematic reviews

This study included 2 systematic reviews [9, 28]. The quality assessment results are presented in Table 2.

Evidence summary

In this study, we have summarized 34 items of best evidence from 10 aspects, including indications and contraindications for the application of pneumatic tourniquets, operator preoperative evaluation, selection and placement of tourniquet cuffs, tourniquet inflation, monitoring during inflation, tourniquet deflation, common complications and prevention, equipment safety, documentation, training and education. Please refer to Table 4 for details.

Table 4 Summary of best evidence for the safe use of pneumatic tourniquets in limb surgery
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Discussion

Clarify the indications and contraindications for the use of pneumatic tourniquets, and improve the preoperative evaluation process for operators

Currently, there is ongoing controversy over the effectiveness of using pneumatic tourniquets due to postoperative complications in patients. Before using a pneumatic tourniquet, enhancing preoperative evaluation content and accurately identifying suitable patients are prerequisites for reducing postoperative complications and ensuring patient safety. High-quality evidence recommends that surgical patients who meet the indications for pneumatic tourniquets should use this device as much as possible for hemostasis [19, 20, 22]. This study aimed to provide clear guidelines on the indications and contraindications for pneumatic tourniquet use, thereby aiding clinicians in making informed decisions to enhance patient safety and reduce complications. There is still controversy over whether patients undergoing knee replacement surgery should use pneumatic tourniquets. Proponents argue that intraoperative pneumatic tourniquet use can provide a bloodless surgical field, enhance the operating area, reduce surgical time, facilitate prosthesis implantation, and extend prosthesis longevity [32,33,34]. Opponents contend that using pneumatic tourniquets can increase overall intraoperative blood loss and hidden blood loss, resulting in more postoperative complications for patients [35, 36]. The reason this study included knee arthroplasty in the indications for pneumatic tourniquet use is primarily due to its role in providing a bloodless surgical field and an optimal operating area. However, in the past, only a limited number of studies provided a simple evaluation of this effect, without quantitative assessment. Additionally, most studies in the past focused on various postoperative complications that did not significantly impact the long-term outcomes of knee arthroplasty [37]. This is also the reason why joint surgeons still routinely use this device for hemostasis during surgery, given the increasing frequency of complications related to pneumatic tourniquets. For patients with relative contraindications, operators should heighten their awareness of risk assessment and thoroughly evaluate the factors associated with tourniquet-related complications. For example, in patients over 60 years old, the use of a tourniquet should be approached with caution due to the increased risks of delayed postoperative limb muscle recovery, muscle atrophy, and pulmonary embolism. Additionally, the risk of neurological complications, such as nerve damage, increases by approximately 0.7 times for every 10-year increase in age, particularly when tourniquet inflation exceeds 120 min [19]. Operators should also carefully assess the risks in pediatric patients [22], those with an increased risk of venous thromboembolism (VTE), and those with low preoperative hemoglobin levels. In patients with a high body mass index (BMI), especially those with a BMI > 30 kg/m², the use of a tourniquet should be cautiously considered due to the increased risks of delayed functional recovery, postoperative limb swelling and pain caused by higher inflation pressures, and an elevated risk of pulmonary embolism [19–20, 22]. Meanwhile the operator should complete the preoperative assessment include tourniquet type, size, placement, and pressure settings, etc. [20]; Evaluate pulse, temperature, capillary refill, condition of the distal skin, sensory of the patient’s limb and motor responses compared between both limbs [19]; Assess whether the patient has a history of local anesthetic allergies [20]; check with a surgeon or anesthesiologist to ensure the safety of use, especially for patients at risk of complications. During the operation, tourniquet operators should also strengthen communication with the doctor and pay attention to the patient.

Proper selection of tourniquet cuffs and placement locations, and individualized setting of inflation pressure and time

Selecting the correct tourniquet cuff size, and shape, placing it in the optimal position can help maintain pressure consistency, visibility, and cuff fit, reduces potential complications such as skin damage, and is beneficial for patient safety [19]. One of the primary objectives of this study was to provide a framework for the appropriate selection of tourniquet cuffs and the individualized setting of inflation pressure, which are crucial steps in minimizing complications and ensuring effective hemostasis during surgery. All existing evidence recommends selecting an appropriate type and model of cuff based on the patient’s limb circumference and shape [19, 20, 22]. Encountering obese or muscular patients during surgery, the cuffs cover the body in a conical shape, the use of a straight cuff may lead to uneven pressure distribution across the cuff, with excessive pressure concentrated at positions with a larger limb circumference, to some extent, it will increase the risk of injury in this area. In contrast, contour cuffs can reduce excessive pressure on local limb areas, significantly lowering the cuff pressure required for vascular occlusion in both adults and children [20].

Before inflating the cuff, blood removal from the limb can help create a relatively bloodless surgical area, however, currently there is no unified standardized method for limb blood drive, and most of them use alternating squeezing with both hands to drive blood, especially when deflation and reinflation are required. Related studies [19] have indicated that compared to using elastic bandages, alternating squeezing with both hands to expel blood increases postoperative pain and the likelihood of tension induced blisters in patients. Therefore, it is recommended to use elastic bandages and raise the limbs to expel blood, For patients with recent plaster casts, infections, closed fractures, or malignancies, exsanguination can be achieved by elevating the arm to 90°or the leg to 45°for 5 min; for all other patients, an elastic bandage is suitable for exsanguination [19–20], sterile elastic bandages should be prepared for use during limb blood removal after deflation but before reinflation.

Regarding the initial pressure setting for the tourniquet, there is currently no national standard, most clinical applications are set to standard pressure. Ding [4] found that personalized pressure setting based on Limb Occlusion Pressure (LOP) significantly reduced the incidence of postoperative pressure related complications compared to standard pressure, while maintaining the same surgical time and field. High-quality evidence recommends setting personalized initial pressure, suggesting the preference of using LOP combined with limb circumference to add an appropriate margin for setting the initial inflation pressure. For patients who meet the criteria, setting the pressure based on systolic blood pressure (SBP) is also recommended.By focusing on the importance of personalized pressure settings, this study aims to establish a more reliable approach to tourniquet use, thereby improving surgical outcomes and reducing the risk of pressure-related injuries. Currently, there is a lack of research on the establishment of safety margin parameters, further high-quality randomized controlled trials with large sample sizes and multiple centers are needed in the future.

Follow and Monitor the Operation Procedure of Pneumatic Tourniquets, keep good records of usage monitoring and prevention and treatment of complications

Relevant studies have found that prolonged with inflation time, the incidence of postoperative complications will significantly increase. For every 30-minute increase in inflation time, the risk of nerve injury triples [20]. Additionally, inflation times exceeding 100 min can lead to increased patient discomfort [17]. High-quality evidence [17–20, 22−24] recommends minimizing inflation time, strictly adhering to the operation procedure, timely detection of equipment malfunctions and operational errors to avoid patient injury [38]. The purpose of this study also includes reinforcing the adherence to operational procedures and ensuring meticulous monitoring during the use of pneumatic tourniquets, which is essential for preventing complications and enhancing patient safety. Rapid deflation of the tourniquet can result in a significant influx of blood into the limbs, causing a sharp drop in blood pressure reduction and potentially leading to hypovolemic shock. Therefore before deflating the tourniquet, the operator should communicate with the surgeon and anesthesiologist ensure the systolic blood pressure is above 90 mmHg, otherwise rapid volume replacement and, if necessary, vasopressor administration should be performed before deflation. And also during deflation, the limb should be slowly lowered [22]. Additionally, rapid deflation can introduce metabolic byproducts from ischemic limbs into the bloodstream, such as lactate, to alter the body’s internal environment and cause ischemia-reperfusion injury. Therefore, it is essential to deflate slowly, strictly prohibit removing the tourniquet without prior deflation, and monitor the patient’s vital signs during deflation, maintaining them within the normal range to ensure patient safety [39]. Proactive prevention of complications and effective management of related adverse events should also be emphasized. If a tourniquet related burn [27] is suspected in the operating theatre, we should detail the documentation of the site and dimension of the injury, skin preparation fluid and duration of contact, digital photography, upload the patient record, and then discuss with a plastic surgical and/or tissue viability team. If a tourniquet related burn is confirmed, an ongoing management plan should be documented, which must include shared decision making with a plastic surgical and/or tissue viability team.

Regular maintenance, reasonable recording of usage, strengthening education and systematic training for medical staff

As a routine hemostatic instrument used in limb surgery, if a malfunction occurs during use, it will seriously affect the hemostatic effect and patient safety. Therefore, pneumatic tourniquets should be included in the department’s instrument and equipment maintenance plan, with regular maintenance by dedicated personnel and proper calibration of pressure settings to ensure the integrity and functional excellence of the equipment and its accessories.This study aims to underline the importance of regular maintenance and systematic training for medical staff to prevent operational errors and ensure the continued safe use of pneumatic tourniquets in clinical practice. In addition, as a potential source of postoperative infection for patients [40], Cultures of tourniquets demonstrated colonisation with bacteria and fungi most of the isolates belonged to the normal flora of the skin and staphylococci formed the predominant isolate, which is the most common organism that causes deep wound infection [41]. In clinical practice surgeons always place cuff on the operative limb of the patient without gloves, after anesthesia induction and prior to hand hygiene. And then prepare the limb for antisepsis till the cuff was draped with sterile sheets.Although sterile drapes preclude the cuff from contacting with the operating field, but the passage of bacteria through fabrics has been identified more so when the fabric is moist. The Association of Operating Room Nurses (AORN) has recommended that Clean and disinfect reusable cuffs and bladders after each use with a facility-approved disinfectant in accordance with the manufacturer’s IFU [19], which were 90% effective in reducing tourniquet contamination [42]. Therefore in our clinical practice pneumatic tourniquets requires cleaning, disinfection, and proper storage of reusable cuffs to avoid cross infection between patients caused by cuffs. For cuffs that cannot be thoroughly cleaned, they should be discarded directly and the reuse of disposable cuffs is prohibited. During the use of pneumatic tourniquets, medical staff should keep relevant records encompass the evaluation of skin condition, vascular integrity, neurological and muscular functions, sensory responses, and limb occlusion pressure. Additionally, record details such as cuff size and placement, operator information, skin protection measures, pressure settings, inflation and deflation times, total inflation time, initial blood pressure post-inflation, reperfusion time, systemic responses to ischemia and reperfusion, communication regarding critical observations (i.e., recipients, content, and timing), and system identification information [19–20, 22]. These records can help us timely and effectively handover with the patient’s postoperative recovery team, and provide comprehensive nursing services for patients. If an adverse event occurs, medical staff should promptly and in detail record the event process, such as time, type, symptoms, and possible causes of malfunction. All materials should be retained as much as possible, and details of the adverse event should be reported according to the policies and procedures of the medical institution, including equipment identification, maintenance, and usage information.

The AORN “Pneumatic Tourniquet Safety Guideline” recommends systematic training for interdisciplinary teams, risk management personnel, anesthesiologists, surgeons, perioperative nurses, and other personnel involved in auxiliary procedures, including perioperative leaders [43], to enrich the theoretical knowledge of team members and enable them to proficiently master operational skills, This can effectively prevent and calmly deal with various problems that may arise during the use of pneumatic tourniquets. At present, there is limited literature on training related to the operation of pneumatic tourniquets. In the future, targeted safety education on the use of pneumatic tourniquets should be based on the knowledge, attitudes, and practices of orthopedic surgical staff [44]. This includes standardized training in preoperative assessment, equipment operation, intraoperative monitoring, postoperative patient observation and documentation. Enhancing awareness of the risks associated with pneumatic tourniquet use and improving operational proficiency and accuracy are crucial to preventing adverse events. The structured risk management approach for surgical errors by Houben and Pascher [45] can be adapted through simulation training and case sharing to promote growth among personnel involved in tourniquet use, thereby reducing operational errors. Additionally, the cognitive training model proposed by Anderson et al. [46] can be referenced to enhance the skills and knowledge base of medical staff. Specialized training for pneumatic tourniquet operators should focus on the selection, placement, fixation of cuffs for different patients, pressure settings as well as adjustments through visual-tactile simulation training [47] and computer-assisted training [48] to finish the entry-level training and assessments. Regular training sessions should be held to address changes in tourniquet brands and models, ensuring that operators are proficient and minimizing errors due to the variety of tourniquet types.

Limitation

Although this study comprehensively summarized the evidence on the safe use of pneumatic tourniquets in patients undergoing limb surgeries, the study results may be affected by different regional, racial and cultural background. Furthermore, we only searched English and Chinese databases without literature published in other languages in this study. In future studies these evidence should be continuously updated, and appropriate evidence should be selected based on the suitability, feasibility, effectiveness and clinical practice to enhance the implementation of such evidence.

Conclusion

This study summarizes the best evidence for the safe use of pneumatic tourniquets in patients undergoing limb surgeries from 10 aspects 34 items. This can provide reference for clinical medical staff to safely use pneumatic tourniquets, but as the evidence comes from different countries, it is recommended to select and apply evidence in clinical practice based on the patient’s own condition and the actual situation of the hospital. At present, there is still a lack of high-quality randomized controlled trials for the setting of personalized initial pressure and safety margin parameters. In the future, further research can be conducted to improve the safety and hemostatic effect of pneumatic tourniquets.

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Authors and Affiliations

  1. Department of Anesthesiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China

    Guangying Liu, Liyun Xiao, Xuetong Zhou & Min Teng

  2. Department of Plastic and Cosmetic Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China

    Jianmin Ma

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Contributions

Gy L contributed to the design of the work, the Literature acquisition, analysis and paper writing. Ly X, Xt Z, MT contributed to the Literature acquisition, analysis and interpretation of data. JM M supervised the writing of and revision of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Jianmin Ma.

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Liu, G., Xiao, L., Zhou, X. et al. Summary of the best evidence for the safe use of pneumatic tourniquet in limb surgery. BMC Surg 24, 281 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12893-024-02579-w

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BMC Surgery

ISSN: 1471-2482

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