HAND/PERIPHERAL NERVE

Oxygen Reduces Tourniquet-Associated Pain:

A Double-Blind, Randomized, Controlled Trial
for Application in Hand Surgery
Natalia White, B.M.B.Ch.,
M.A.
Thomas D. Dobbs,
B.M.B.Ch., M.A.
George R. F. Murphy,
M.R.C.S.
Khurram Khan, M.R.C.S.
Jeremy P. Batt, B.M.B.S.,
M.Sc., S.E.M.
Lucy K. Cogswell, F.R.C.S.
Plast.
Oxford and Wiltshire, United Kingdom
Background: Why do limb tourniquets cause pain? If ischemia is the mecha-
nism, can supplemental oxygen reduce pain? The Reducing Tourniquet As-
sociated Pain study investigated whether this simple treatment could extend
tourniquet tolerance time to facilitate hand surgery under local or regional
anesthesia.
Methods: The Reducing Tourniquet Associated Pain study was a double-blind,
randomized, controlled trial of healthy volunteers. Participants received either
50% inhaled oxygen or air placebo via a face mask for 3 minutes before and up
to 30 minutes after upper arm tourniquet inflation to 250 mmHg. Pain scores
were recorded at 2-minute intervals using a validated 100-mm visual analogue
scale. The primary outcomes were (1) difference in visual analogue scale score
and (2) difference in time taken to reach visual analogue score of 40 mm or
more in oxygen and air groups.
Results: Fifty participants enrolled and, after exclusion criteria were applied,
46 were analyzed (oxygen, n = 23; air, n = 23). Oxygen supplementation was
associated with a 29 percent mean reduction in pain on visual analogue
scoring compared with air placebo over the entire period of inhalation
(p = 0.027). Oxygen also extended the time to visual analogue scale score
of 40 mm or more by a mean of 6 minutes compared with air placebo
(p = 0.008).
Conclusions: Oxygen is a readily available, low-risk, low-cost treatment that
significantly reduced tourniquet-associated pain in this study and significantly
increased the time taken to reach visual analogue scale score of 40 or more.
The authors recommend oxygen to facilitate hand surgery under a tourniquet
and when a regional block fails to control tourniquet pain. (Plast. Reconstr.
Surg. 135: 721e, 2015.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

From the Department of Plastic and Reconstructive Surgery,
Oxford University Hospitals NHS Trust; and the Depart-
ment of Plastic and Reconstructive Surgery, Salisbury Dis-
trict Hospital, Salisbury NHS Foundation Trust.
Received for publication September 2, 2013; accepted March
25, 2014.
This trial is registered under the name A Study Investigat-
ing Ways to Make Local Anaesthetic Hand Surgery Less
Painful: Reducing Tourniquet Associated Pain (ReTAP),
Clinical Trials.gov identification number NCT01611064
(https://clinicaltrials.gov/ct2/show/NCT01611064).
Presented at the British Society for Surgery of the Hand Au-
tumn Scientific Meeting, in York, United Kingdom, October
11 through 12, 2012; and the British Association of Plastic,
Reconstructive and Aesthetic Surgeons Summer Scientific
Meeting, in Nottingham, United Kingdom, June 19 through
21, 2013.
Copyright 2015 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000001028
T
ourniquets are commonly used to provide
a nearly bloodless field in upper or lower
limb surgery, under either general, local, or
regional anesthesia. Although serious complica-
tions associated with tourniquet use have been
Disclosure: The authors have no financial interest
to declare in relation to the content of this article.
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www.PRSJournal.com 721e

reported, they are rare.1 Much more common is
pain associated with tourniquet use, especially in
the upper limb.2 This has a detrimental effect,
not only on patient comfort and satisfaction
with the procedure, but also on the outcome of
the procedure.3 Furthermore, tourniquet-asso-
ciated pain limits the length of operating time,
potentially affecting the quality of surgery and
restricting the type of procedure performed and
therefore increasing the number of patients sub-
jected to the risks of a general anesthetic.
There are a number of theories as to the cause
of tourniquet-associated pain. A neural cutane-
ous mechanism has been suggested, mediated
by unmyelinated slow-conducting C fibers in the
skin.4 These nerve fibers are normally inhibited
by fast myelinated A-delta fibers, but with com-
pression of the nerves by a tourniquet, the A-delta
fibers stop conducting before the C fibers, leav-
ing the C fibers uninhibited, and therefore an
increase in pain is experienced.5
Ischemia of the tissues, especially nerve fibers,
muscle, and skin, has also been suggested as a
cause of pain. Animal and human studies have
demonstrated a fall in the concentration of ade-
nosine triphosphate, oxygen tension, and gly-
cogen distal to a tourniquet, with concomitant
rise in lactate concentration and carbon dioxide
tension.6,7 A change in intracellular pH has been
demonstrated as early as 15 minutes after appli-
cation of a tourniquet. Although it is generally
accepted that a tourniquet can be left in situ for
1.5 to 2 hours before significant damage occurs,
the subtle early changes in tissue metabolism may
be a cause of the pain felt.
A number of interventions have been inves-
tigated to aid reduction in tourniquet-associated
pain. It is shown that changing the tourniquet
position from upper arm to forearm reduces pain;
however, this would only be of use if the forearm
and elbow did not need to be accessed.8 The use
of an N-methyl-d-aspartate receptor antagonist,
magnesium sulphate, given intravenously has also
been shown to reduce tourniquet pain.9 In addi-
tion, it reduced the degree of blood pressure rise
seen in patients undergoing procedures under
tourniquet.
Although there have been many suggested
interventions to reduce tourniquet-associated
pain, these are often limited by practicalities. We
therefore hypothesized that if tissue ischemia is
one of the mechanisms underlying pain, supple-
mentation with inhaled oxygen could reduce
tourniquet-associated pain. Preoxygenation
of the tissues could increase the time before a
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Plastic and Reconstructive Surgery April 2015
painful level of ischemia is reached. We have
also observed that during surgery under tourni-
quet, a small volume of blood enters the limb,
providing oxyhemoglobin and oxygen dissolved
in the plasma. The Reducing Tourniquet Associ-
ated Pain study is therefore a double-blind, ran-
domized, controlled trial of healthy volunteers
to investigate the influence of inhaled oxygen
on tourniquet pain and tourniquet tolerance
time.
PATIENTS AND METHODS
The Reducing Tourniquet Associated Pain
study was a single-center, double-blind, random-
ized, controlled trial of healthy volunteers to assess
the effect of oxygen on tourniquet-associated pain
and tourniquet tolerance time. Subjects were ran-
domized to receive either 50% inhaled oxygen or
air placebo by means of face mask while wearing
an upper arm tourniquet and scoring their pain
(Fig.1). Methods were approved by the Central
University Research Ethics Committee of the Uni-
versity of Oxford (reference no. MSD/IDREC/
C1/2011/125).
Participants
Eligible participants were 18 years of age or
older, of either sex, healthy, and able to give valid
informed consent; and did not meet any exclu-
sion criteria (Table1). NHS staff (nurses, doctors,
porters, and receptionists) and medical students
were recruited for participation through post-
ers, online announcement, e-mail, and word of
mouth. Every participant was reimbursed for their
time (1 hour) with one 10 payment, regardless
of testing outcome. Subjects were provided with
written information (see Figure, Supplemental
Digital Content 1, which shows a sample letter to
volunteers, http://links.lww.com/PRS/B254) and a
verbal briefing before giving written consent to
take part (see Figure, Supplemental Digital Con-
tent 2, which shows a sample participant consent
form, http://links.lww.com/PRS/B255) and com-
pleting a demographic data form (see Figure,
Supplemental Digital Content 3, which shows a
sample participant demographics form, http://
links.lww.com/PRS/B256). Consent was taken by
the principal investigator (N.W.) (International
Conference on Harmonisation of Technical
Requirements for Registration of Pharmaceuti-
cals for Human Use Good Clinical Practice train-
ing certificate no. 26501-1-34349). Testing took
place in a closed hospital bay between February
and May of 2012.
Volume 135, Number 4 Oxygen Reduces Tourniquet Pain

Fig. 1. Flow chart of the Reducing Tourniquet Associated Pain study protocol. ReTAP, Reducing Tourniquet Associated Pain; BP,
blood pressure; VAS, visual analogue scale;

Randomization participant number to one of four different

The principal investigator assigned a partici- conditions:
pant number to each subject on arrival. An online
random number generation program (http:// 1. Condition A, tourniquet to dominant arm
www.randomizer.org) was used to allocate each plus oxygen.

723e

Table 1. Reducing Tourniquet Associated Pain
Randomized Controlled Trial Exclusion Criteria for
Participant Volunteers
Younger than 18 yr
Body mass index >30kg/m2
High blood pressure (systolic pressure consistently >160
mmHg)
Raynaud syndrome (fingers becoming very pale, then
cyanotic/blue, before returning to pink) in the past 2 yr
Raynaud syndrome causing finger necrosis, gangrene, scarring,
or ulceration
Diagnosis of peripheral vascular disease
Vascular surgery to either upper limb
Neurologic condition of either upper limb
Skin condition that may be aggravated by wearing a tight
tourniquet cuff around either one of the upper arms
Diagnosis of COPD or COAD
Diagnosis or family history of sickle cell anemia or thalas-
semia
Use of analgesia in the preceding 24 hr
Chronic pain syndrome
Allergy to any of the materials used in the study
COPD, chronic obstructive pulmonary disease; COAD, chronic
obstructive airway disease.
2. Condition B, tourniquet to nondominant
arm plus oxygen.
3. Condition C, tourniquet to dominant arm
plus air.
4. Condition D, tourniquet to nondominant
arm plus air.
The identity of each condition was known only
by the principal investigator and was recorded
and stored in a sealed envelope. This method
achieved blinded randomization of each subject
to treatment or placebo, in addition to random-
izing the arm of tourniquet wear to avoid any pos-
sible bias resulting from hand dominance.
Interventions
The two interventions in this trial were the
treatment (50% inhaled oxygen) and the pla-
cebo (inhaled medical air). Research Random-
izer (http://www.randomizer.org) was used to
randomly generate a number between 1 and 26
for each gas, and the corresponding letter of the
English alphabet was then used to denote that
gas (e.g., substance W). Substance identity was
known only to the principal investigator and was
recorded and stored in a sealed envelope.
In the treatment group, 100% oxygen was
delivered from a piped hospital supply at a rate
of 10 liters/minute by means of a flowmeter (Dia-
mond Range, Therapy Equipment Ltd., Herts,
United Kingdom) connected to 280cm of pip-
ing (Universal; Shermond, London, United
Kingdom) and a disposable mask (Respironics;
Philips Healthcare, Best, The Netherlands). This
724e
Plastic and Reconstructive Surgery April 2015
equipment was chosen because of local availabil-
ity. According to manufacturer instructions, this
setup delivers an inhaled concentration of 50%
oxygen. In the placebo group, medical air (21%
oxygen) was delivered from a piped hospital
supply at a rate of 10 liters/minute by means of
a flowmeter, piping, and mask described above,
to achieve a maximum inhaled concentration of
21% oxygen.
Blinding
Participants and investigators were blinded to
the identity of the intervention received. Equip-
ment was set up in advance and disassembled by
the principal investigator, who did not partake in
data collection. Piping and masks were labeled
(e.g., substance W) to ensure accurate data collec-
tion and to conceal intervention identity. Wall gas
outlets were obscured from view using an opaque
screen. The gas outlet and flowmeter were oper-
ated by the principal investigator (behind the
opaque screen). Before data analysis, data collec-
tion booklets were blinded by blacking out the
substance letter and test arm. Unblinding did not
occur during this study.
Protocol and Equipment
Subjects lay supine with arms by their sides
on a flat bed with one pillow under their head.
Two layers of 6-inch wool (Formflex; Lantor,
Bolton, United Kingdom) were wrapped around
the widest diameter of the upper arm and a
45-cm tourniquet cuff (Oak Medical Ltd., North
Lincolnshire, United Kingdom) was secured on
top according to Association of Perioperative
Registered Nurses guidelines.10 Cuffs were con-
nected to pneumatic tourniquet machines (Oak
Medical), which were operated according to the
manufacturers instructions. On the nontest arm,
a 30- to 41-cm blood pressure cuff (Dura-Cuf; GE
Medical Critikon, Little Chalfont, United King-
dom) was fitted to the upper arm and a pulse
oximeter (Nellcor; Covidien, Mansfield, Mass.)
was fitted on the little finger. Pulse, blood pres-
sure, and oxygen saturations were recorded
every 6 minutes. Larger sizes of tourniquet and
blood pressure cuffs were available for subjects
with larger arms.
Interventions were administered for 3 min-
utes before tourniquet inflation (prebreathing
period), throughout tourniquet inflation, and
12 minutes after deflation (recovery period). Three
minutes was chosen as the prebreathing time, as
this is a pragmatic amount of time that would
be available in the operating room (e.g., while
Volume 135, Number 4 Oxygen Reduces Tourniquet Pain
preparing the arm) without unduly delaying the
procedure. A standard protocol of arm exsan-
guination was used, which consisted of lifting
the arm to vertical with a clenched fist for 5 sec-
onds before inflation of the tourniquet cuff and
return of the arm to horizontal. This method
was chosen as the most easily reproducible with-
out interinvestigator variability in the amount of
exsanguination achieved. Tourniquets remained
inflated at a constant pressure of 250 mmHg for
a maximum of 30 minutes. Tourniquets were
deflated early if the visual analogue scale score
was 100mm, if the systolic blood pressure was
greater than or equal to 200 mmHg, or at par-
ticipant request. At tourniquet deflation, investi-
gators also removed the cuff and wool.
Data Collection
Data collection was coordinated by blinded
investigators using a standardized data collec-
tion booklet. (See Figure, Supplemental Digital
Content 4, which shows a sample of a data col-
lection booklet, http://links.lww.com/PRS/B257.)
Baseline pain scores, pulse, oxygen saturations,
and blood pressure were measured at times 0
and 3 minutes. Subsequent pain scores were
measured at 2-minute intervals and other obser-
vations were measured at 6-minute intervals. Par-
ticipants recorded their pain score by placing a
pencil mark along a validated, horizontal, 100-mm
visual analogue scale.
Statistical Analysis
A pilot study was conducted and the prelimi-
nary data used for power calculations with the
Harvard power calculation tool (http://hed-
wig.mgh.harvard.edu/sample_size/js/js_paral-
lel_quant.html). We assumed a power of 0.8, a
two-tailed significance level of 0.05, a standard
deviation of 0.089 (as found in our pilot study)
and, as suggested by the literature, a minimally
detectable difference in the standard 100-mm
visual analogue scale of 10 to 14 percent.11 This
gave a sample size of between 22 (at 10 percent)
and 30 participants (at 14 percent).
Statistical methods were determined before
data collection. It was determined that a visual
analogue scale of 100 would be recorded at all
time points following an early deflation of the
tourniquet triggered by either participant request
because of discomfort or reaching a visual ana-
logue scale score of 100mm. This method was
used in both groups so that triggering of early
tourniquet deflation could be reflected in data
analysis, given that this was one of the main ques-
tions in this study.
Data were tabulated and analyzed using
Microsoft Office Excel (Microsoft Corp., Red-
mond, Wash.) and IBM SPSS Version 21 (IBM
Corp., Armonk, N.Y.). One-tailed, independent
samples t tests were used to assess the main effect
of gas inhaled as between-group analysis of mean
visual analogue scale at specific time points. The
hypothesis assumed directionality that inhaled
oxygen was theorized to reduce visual analogue
scale score compared with inhaled air. A two-
tailed independent samples t test was used for
between-group analysis to assess the main effect
for handedness, as no assumptions of direction-
ality could be made. Paired t tests were used to
assess a within-group analysis of visual analogue
scale directly compared between two time points.
Univariate analysis of variance was used to estab-
lish any potential interactions between the main
effects of inhaled gas and the main effect of hand-
edness. An intention-to-treat analysis was used
for between-group analysis of the time taken to
reach predetermined visual analogue scale levels.
According to convention in pain research, a visual
analogue scale of 40mm in participants was taken
to represent the maximum acceptable pain toler-
able to patients in the clinical setting. Statistical
significance was set at p < 0.05. Graphs and tables
were produced using Microsoft Office Excel.
RESULTS
Fifty participants enrolled and, after exclu-
sion criteria, 46 were analyzed (oxygen, n = 23; air,
n = 23) (Fig.2). The age range, sex, hand domi-
nance, occupations, and comorbidities were com-
parable in the oxygen and air groups (Table2). In
both groups, the average age of participants was
mid twenties, there was a predominance of men,
and more than half of participants were medical
students.
Oxygen Significantly Reduces Visual Analogue
Scale Pain Scores during Tourniquet Use
During the prebreathing period, two baseline
pain scores were collected. In both air and oxygen
groups, 21 of 23 participants scored 0mm on the
visual analogue scale for both baseline readings,
with the remaining four participants all scoring
less than 10mm on both baseline readings. These
visual analogue scale scores indicate a low level of
pain in both groups before tourniquet inflation.
There was no significant difference in pain scores
between groups at baseline (p = 0.47).
725e

Fig. 2. Consolidated Standards of Reporting Trials 2010 flow diagram. (Adapted for the Reducing Tourniquet Associ-
ated Pain Study.) CONSORT, Consolidated Standards of Reporting Trials; ReTAP, Reducing Tourniquet Associated Pain.
Tourniquets were inflated for a maximum of 30
minutes while participants inhaled either oxygen
or air. Visual analogue scale pain scores increased
with time during this period in both groups. How-
ever, lower visual analogue scale pain scores were
recorded for participants inhaling oxygen (Fig.3)
and on five occasions demonstrated a value of
p < 0.05. A between-group analysis of average visual
analogue scale pain scores across 30 minutes
was also significantly lower in the oxygen group
(p = 0.027). On average across all time points, oxy-
gen supplementation was associated with a 29 per-
cent mean reduction in visual analogue scale score
compared with air placebo, which amounted to a
10-mm difference in visual analogue scale score.
Immediately after tourniquet deflation, all
participants entered a 12-minute recovery period
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Plastic and Reconstructive Surgery April 2015
where they continued to inhale their gas (Fig.4).
In both groups, visual analogue scale pain scores
decreased toward baseline during this period.
There was a trend toward participants in the oxy-
gen group scoring less on the visual analogue
scale than those in the air group; this association
reached a value of p < 0.05 at 8 minutes and at 12
minutes (p = 0.046 and p = 0.041, respectively).
Oxygen Significantly Extends the Time Taken to
Reach a Visual Analogue Scale Score of 40 mm
According to convention in anesthesia and pain
research, a visual analogue scale score of 40mm
experienced by study participants was taken to rep-
resent the maximum acceptable pain tolerable and
the point at which a tourniquet might be removed
because of pain in clinical practice. We therefore
Volume 135, Number 4 Oxygen Reduces Tourniquet Pain

Table 2. Participant Demographics by Group for the oxygen extends tourniquet tolerance time up to
Reducing Tourniquet Associated Pain Randomized this maximum acceptable pain threshold by greater
Controlled Trial Results than 6 minutes. After 30 minutes, 20 participants
Oxygen Air in the air group had reached visual analogue scale
score greater than or equal to 40mm, whereas in
No. of patients 23 23
Sex the oxygen group, only 14 participants had reached
Female 10 9 the same pain level, suggesting that the pain from
Male 13 14 a tourniquet worn over 30 minutes was more likely
Age, yr
Mean 28 25 to be tolerable in the oxygen group. Because of the
Range 2151 1951 imposed maximum time of tourniquet wear (set at
Dominant hand 30 minutes for ethical and safety reasons), we were
Left 2 4
Right 21 19 unable to accurately test overall tourniquet toler-
Arm tested ance time.
Left 11 10
Right 12 13
Dominance of arm tested Oxygen Does Not Affect Pulse, Arterial
Dominant 12 11 Oxygen Saturation, or Blood Pressure during
Nondominant 11 12 Tourniquet Use
Smoking status
Smokers 4 3 Pulse rate, arterial oxygen saturation, and blood
Nonsmokers 19 20 pressure were measured at baseline and subsequent
Occupation
Medical students 12 15 6-minute intervals during tourniquet inflation
NHS employees 10 6 and recovery. There was no significant difference
 Other 1 2 between the average participant pulse rate over
Significant comorbidities or 0 1, asthma (inhaled
medications steroids and time in the oxygen and air groups. There was, how-
salbutamol); 1, ever, a trend in both groups for participant pulse
diabetes mellitus rate to decrease slightly with time until the point of
(metformin)
tourniquet deflation, at which time the pulse tran-
siently rose, although this did not reach statistical
analyzed the time taken to reach a visual analogue significance in either group. A similar, nonsignifi-
scale score greater than or equal to 40mm and the cant trend was demonstrated for mean participant
numbers of participants reaching this pain level systolic blood pressure, with no difference between
during the study (Fig.5). Participants inhaling air the oxygen and air groups. Arterial oxygen satura-
took, on average, 15.3 minutes to reach a visual tions, measured noninvasively with a pulse oxim-
analogue scale greater than or equal to 40mm, eter on the contralateral hand, remained between
whereas this time was extended to 22.0 minutes in 98 and 100 percent in the air group and stayed at
the oxygen group (p = 0.008). This suggests that 100 percent in the oxygen group.

Fig. 3. Mean visual analogue scale (VAS) scores for all participants in the oxygen and air groups during
30 minutes of tourniquet inflation.

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 Plastic and Reconstructive Surgery April 2015

Fig. 4. Mean visual analogue scale (VAS) scores for all participants in the oxygen and air groups during
12 minutes of recovery after tourniquet deflation.

Fig. 5. Number of participants with visual analogue scale (VAS) pain scores less than 40mm at each time point during tourniquet
inflation in the oxygen and air groups.

Handedness Does Not Affect Visual Analogue
Scale Pain Scores during Tourniquet Use
Each participant was randomized to wear the
inflated tourniquet on either their dominant or
their nondominant arm, with an approximately
equal spread in each group (Table2). The ratio
of left-handed to right-handed participants was
also comparable (two of 23 left-hand-dominant
patients in the oxygen group and four of 23 left-
hand-dominant patients in the air group). There
was no significant difference in visual analogue
scale score at any time point between dominant
and nondominant groups, or at the end point of
tourniquet inflation (p = 0.21). There was also no
significant interaction between gas inhaled and
the arm on which the tourniquet was inflated

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Volume 135, Number 4 Oxygen Reduces Tourniquet Pain
(p = 0.13). There was no significant difference in
the time taken to reach visual analogue scale score
greater than or equal to 40mm between dominant
and nondominant groups (p = 0.86) and there was
no interaction with gas inhaled (p = 0.30).
DISCUSSION
The results of this randomized controlled
trial suggest that oxygen inhalation could reduce
tourniquet pain by nearly one-third and extend
the time taken to reach a widely acceptable pain
threshold for patients (visual analogue scale score
40mm) by more than 6 minutes. We hypothe-
size that the changes in tissue metabolism (e.g.,
increases in lactate concentration and carbon
dioxide tension) brought about by ischemia
resulting from tourniquet use may be minimized
by the use of preoxygenation and continued
oxygen inhalation during tourniquet inflation.
Increased oxygen loading and increased amounts
of dissolved oxygen may facilitate more aerobic
and less anaerobic respiration of the tissues.
Previous work estimated a minimum clini-
cally significance difference for visual analogue
scale pain scoring of 13mm.12 In this study, the
average difference was 10mm, although this was
statistically significant. The effect of oxygen may
be greater in clinical practice, where the patient
has frequently been subject to injury and has the
additional stress of undergoing surgery. Our par-
ticipants were uninjured and not subject to extra
stress. We therefore expect a similar, if not greater,
effect to be seen in clinical practice. The greater
than 6-minute prolongation of visual analogue
scale score less than or equal to 40mm is also
likely of more significance in clinical practice.
This study also raises many questions. We have
been unable to ascertain whether there is increased
oxygen tension distal to the tourniquet secondary
to oxygen use. Further work could examine arte-
rial blood samples to analyze the partial pressure
of oxygen at various times during tourniquet infla-
tion in oxygen and air groups. We have also been
unable to ascertain whether it is preoxygenation,
continuous supplemental oxygen, or both that
contribute to the effect seen. Addition of a study
arm testing participants with preoxygenation
only may answer this important question. We are
unable to say whether oxygen supplementation
has a central effect on pain and the inhibitory
pathways modulating pain perception.
Criticisms of the study include that it did not
use a crossover design, where pain in the two dif-
ferent conditions could be compared within the
same patient. However, the resultant ischemic pre-
conditioning after tourniquet use could have sig-
nificantly affected the results if a crossover design
had been used.13 The early phase of precondition-
ing occurs for up to 4 hours and the late phase in
skeletal muscle could last up to 4 days. It would
be difficult to recruit participants willing to attend
on two separate occasions 4 days apart. The results
may also be affected by the volunteers preconcep-
tions about tourniquet pain in a crossover study.
CONCLUSIONS
We recommend the use of supplemental
oxygen for any patient undergoing a procedure
under an upper limb tourniquet. Oxygen has a
minimal side-effect profile and negligible cost. We
believe it is a useful and safe means of improving
the patient experience of hand surgery.
Natalia White, B.M.B.Ch., M.A.
The Old Bakery
37 Riverside
Wilton, Wiltshire SP2 0HW, United Kingdom
natalia.white@hotmail.co.uk
acknowledgments
Pneumatic tourniquet machines and cuffs were a
loan from Oak Medical Services Ltd. All other equip-
ment was a loan from Oxford University Hospitals NHS
Trust.
Participant reimbursement was personally funded
by the corresponding author. The authors sincerely thank
Dennis Ecuyer and Oak Medical Ltd., who very kindly
provided tourniquet cuffs and pneumatic tourniquet
machines for this study. The authors also thank Benja-
min White, Oliver Perkins, and Daniel Pope, who very
kindly assisted with data collection.
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