Cuffed versus uncuffed pediatric endotracheal tubes.

To the Editor: Textbooks ascribe negligible risk to standard noninvasive blood pressure (NIBP) devices.1,2 We report a complication from an appropriately placed cuff. Consent for publication was obtained in conformance with institutional publication consent guidelines. The cuff was placed on an athletic male and used during supine induction, then immediately inactivated after radial arterial catheter insertion and prone-positioning for a six-hour procedure. Postoperatively, marked erythema of the NIBP site and pronounced swelling of the proximal upper arm was observed. Painful, stocking-glove numbness in the dorsum of the hand and fingers presented. Orthopedic consultation confirmed significant edema of the upper extremity and compressive neurapraxia, which resolved spontaneously by the next day. Standard NIBP placement occurred with the arm in full extension. After assuming the prone position, the arm was flexed at the elbow, increasing biceps muscle diameter. This is typically tolerated on a daily basis without adverse effects. With this athletic patient, however, critical constriction occurred beneath the non-cycled cuff with flexion, leading to the signs and symptoms described. While a rare complication, cuff placement cannot be assumed to be innocuous, particularly in limbs subsequently flexed, even with inactivated cuffs. Forearm cuff placement may be preferred in such instances, as diameter is not subjected to such significant changes with positioning. Occilometric measurements do not require placement on the upper arm, and smaller cuffs can be used with smaller diameter locations. We report for the first time a significant tourniquet effect from an appropriately applied NIBP cuff, occurring intraoperatively during prolonged non-utilization, and while in the prone position.