Patient Positioning

Dr. Shailendra.V.L. Specialist in Anesthesia, Al Bukariya general hospital.

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Introduction

Important to know the various implications of patient positioning during surgery Because of the various physiological effects it exerts on the systems In the last 2 decades newer surgical techniques developed due to advances

In electronics In technology as a whole Better understanding of physiology

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Goal of positioning

Goal of surgical positioning is to facilitate surgeons technical approach while balancing risk factors All surgical positions have position-related risks

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Physiologic effects of change from vertical to horizontal position

Body responses to alteration of positions is due to gravity Effects of Gravity:

On blood in venous / arterial / pulmonary systems On pulmonary mechanics On pulmonary perfusion

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Erect position to Supine position

Cardiac output on assuming supine position Venous blood from lower body flows back To heart Stretches atrial wall (Laplaces law) Stroke volume blood pressure (clinically normal BP observed)
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Baroreceptors in Aorta via Vagus nerve

Baroreceptors in Carotid via sinus Glossopharyngeal nerve

Medulla Oblongata efferent Parasympathetic activity HR SV Contractility Little change in BP noted

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Erect posture effect on pulmonary system

Abdominal contents & diaphragm move caudally FRC TLC

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Supine posture effect on pulmonary system

Abdominal contents move cephalad FRC TLC

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Supine position

Commonest position for most of the surgeries Care should be exercised to prevent injuries to the anesthetized patient

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Supine position Pressure points

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Arm tucking in supine position

One arm if needed to keep by the side of the patient , the draw sheet should cover the arm as shown & tucked under the patient to prevent injury to brachial plexus
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Arm tucking

Note the arms is tucked using draw sheet & arm is secured by the side of the patient

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Lithotomy

Used in gynecology & urology procedures Elevation of legs promotes translocation of vascular volume centrally Areas supporting weight of legs prone for nerve injury Legs supported at knee & suspended by stirrups
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Lithotomy positioning - I

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Lithotomy positioning - II

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Final lithotomy position

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Lithotomy position with stirrups

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Lithotomy position

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Urology -- Lithotomy position

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Lithotomy position

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Various types of Lithotomy stirrups

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Lithotomy position

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Nerve injuries in lithotomy

Peroneal nerve injury Saphenous nerve injury Femoral nerve injury Obturator nerve injury

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Lithotomy position Nerve injuries

Saphenous nerve Peroneal nerve Femoral nerve Obturator nerve

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Lithotomy nerve injuries

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Nerve injuries in lithotomy

Peroneal nerve injury: Pressure of head of fibula by bar or support structures compresses nerve Saphenous nerve injury: Pressure on medial condyle of tibia compress nerve Femoral nerve injury: Due to angulation of thigh such that inguinal ligament is stretched & compresses nerve Obturator nerve injury: Due to greater degree of thigh flexion there is stretching of nerve as it exits the obturator foramen
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Lithotomy position - problems

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Compartment syndrome in lower limbs during lithotomy position

Long duration of lithotomy position Tightening of leg straps Dorsi-flexion of ankle Surgeon leaning on suspended leg for long duration

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Upper limb injury during lithotomy position

Compartment syndrome of hand occurs when hand is tucked under the buttocks & OR table Extension of upper limb > 90* causes traction of brachial plexus

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Chemical burns in lithotomy position

Rare fortunately Pooling of preparation solutions at buttock & lower back causes chemical burns

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Lateral position

A pad placed under the head Arm perpendicular to torso, either on pillow or an over arm rest Pillow between the legs Arm taped on this position Care taken that tape does not press ulnar nerve @ elbow or radial nerve @ radial groove
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Lateral position

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Lateral position

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Lateral position

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Higher chest exposure in lateral position

Arm kept in more anterior plane to body to prevent stretching of brachial plexus Lower chest supported by axillary role

Supports weight of thorax Prevents compression of shoulder & axilla Prevents brachial plexus injury in axilla

Palpate Radial artery of dependent arm to ensure there is no compression

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Lateral position with kidney bridge

This position is used for surgeries on the kidney & ureters Kidney bridge is elevated & this opens up the retro pelvic space for optimal exposure

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Lateral position with kidney bridge

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Lateral oblique Three quarters prone position

Used for exposure of posterior cranial fossa Head rotated from supine to lateral Head holder pins are inserted Upper leg is bought forward & flexed slightly Lower leg is left straight Axillary role placed under chest to support weight of body Lower shoulder bought to forward edge of bed or just slightly over it Upper arm placed downward near the side comfortably 30 June 2012 38 Patient looks like he is trying to look at the floor

Lateral oblique position

Assistant Surgeon

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Lateral oblique position

Assistant Surgeon

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Lateral oblique position

Assistant Surgeon

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Lateral oblique position

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Lateral oblique position

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Lateral oblique position

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Problems in lateral oblique position

In obese patients difficulty in placing lower arm below torso Cause considerable weight on humeral head & acromion Lower breast can get compressed pressure on nipple & areola Extreme neck flexion cause cervical spinal cord hypo-perfusion ECG electrodes can cause pressure necrosis
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Prone position

Lumbar Laminectomy Spinal instrumentation

Steffis plating Harringtons rod

Pilonidal sinus excision

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Prone position - problems

Careful positioning from supine position Prevent pressure on abdomen Prevent pressure on eyes Pillows to rest the lower limbs Prevent pressure on male external genitalia

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Prone position induction on trolley

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Prone position Ist stage

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Prone position

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Prone position

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Prone position

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Prone position with laminectomy frame - pressure points

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Trendlenberg s position

Modification of supine position Places head down along with the whole body Advantages of this position:

Moves viscera cephalad Helpful in lower abdominal surgeries To venous return after spinal anesthesia To central blood volume to facilitate central vein cannulation To minimize aspiration during regurgitation
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Effects of Trenlenberg s position

CVP ICP IOP myocardial work pulmonary venous pressure pulmonary compliance FRC Swelling of face, eyelids, conjunctiva & tongue observed in long surgeries
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Trendlenburg position

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Reverse Trenlenbergs position

This is the opposite of Trenlenbergs position This position places head end up & feet down This position helps in caudal movement of abdominal contents Used in upper abdominal laparoscopic surgeries Lap gastric banding Causes venous pooling in lower limbs To prevent DVT stockings is a must
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Reverse Trenlenberg position

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Jack knife position ( Kraske )

Used for anal surgeries, pilonidal sinus excision Places patient prone with head & feet at a lower level

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Jack knife position

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Knee chest position

Further exaggeration of knee-chest position Used for sigmoidoscopies or lumbar laminectomies Severe hypotension is seen due to pooling of blood in the legs

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Knee chest position pressure points

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Orthopedic surgeries positions

Orthopedic fracture table Wattson-Jones

Body section to support head & thorax Sacral plate for pelvis Perineal post Adjustable foot plates

Table maintains traction of the extremity Allows surgical & fluroscopic access Anesthesia induced & then the patients are positioned on this table (pain) Arm on # side placed so that it will not interfere with surgical access
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Orthopedic surgeries needing Wattson-Jones table

# shaft femur for Interlocking DHS with plate Inter-trocanteric # femur

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Wattson Jones table used for Ortho surgery

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Wattson Jones table used for Ortho surgery

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Lateral position on Wattson Jones table

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Problems with this position

Brachial plexus injury

Due to > than 90* extension of the upper limb

Due to long surgeries & compression Due to pressure of the perineal post

Lower extremity compartment syndrome

Pudendal nerve injury

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Positions for shoulder surgery

Beach chair / barber chair / semi-recumbent position Provides both anterior & posterior access to shoulder Provides freely mobile upper limb Endotraheal tube secured well to prevent accidental extubation
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Beach chair position for shoulder surgery (Semi Fowler position)

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Sitting position--Fowler position

For posterior cranial fossa position Better surgical exposure Less tissue retraction & damage Less bleeding Less cranial nerve damage More complete resection of lesion Ready access to airway, chest & extremities Modern monitoring gives early warning of venous air-embolism
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Sitting position - Neuro surgery

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Sitting position pressure points

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Sitting position

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Relative contra-indication to sitting V-P shunt in position position

Cerebral-ischemia upright awake Patent foramen ovale & R L shunt Cardiac instability Extremes of ages

Left AP < RAP -------Platypnea Orthodeoxia Patient becomes deoxygenated on assuming erect position Arterial gradients reverses on assuming erect position These patients open up foramen ovale & VAE can 30 June 2012 75 enter systemic circulation

Problems in sitting position

Venous air embolism Hypotension (prevented by stockings) Arms if not well supported cause brachialplexus stretching

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Venous air-embolism

Most feared complication in sitting position With subsequent PAE to the brain

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Air embolism

Right atrium with air embolus CVP catheter in situ

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Air embolism monitor warnings

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Mandatory monitoring

EKG BP SpO2 EtCO2 Doppler CVP Pulmonary artery catheter

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Pre-cordial Doppler device

Most advocated monitoring Reasonably priced Relatively easy to use Non-invasive Sensitive Sounds heard both by surgeons & anesthesiologist
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Mechanism of peripheral nerve injury

2 basic forces impairing nerve function

Nerves that course superficially for long distances are prone for stretch injury Nerve that pass over bony structures over small area prone for compression Final result nerve ischemia nerve injury Ischemia > 30 minutes result in nerve palsy

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Types of nerve injury

Neuropraxia Axonotomasis Neurotomasis

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Neuropraxia

Occurs with loss of function Without demonstrable anatomic injury Related to positioning under anesthesia Recovery complete in 6 weeks

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Axonotomesis

Occurs with anatomic disruption of axons but preservation of nerve sheath & connective tissue Axon degenerates distal to lesion Regenerates @1mm / day Function gradually returns but in longer nerves of upper limb will take upto 1 year Physical therapy helpful to prevent degeneration of joints & muscles
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Neurometesis

Results in axon, sheath & connective tissue disruption Leads to degeneration of axon distal to injury

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Course of Upper limb nerves

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Brachial plexus in the axilla

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Coarse of nerves in thigh

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Coarse of nerves in leg

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Cubital-tunnel external compression syndrome

Ulnar nerve passes through cubital tunnel of elbow Forearm pronated will cause compression of ulnar nerve Flexion @ elbow > 90* tenses arcuate ligament & reduces the tunnel size & compress nerve

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Ulnar nerve injury

Ulnar nerve pressure

Pronated arm

Supinated arm

Unpadded elbow

Elbow padded

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Ulnar nerve @ cubital fossa

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Eye injury
Excessive pressure on eyes more than Venous pressure Venous collapse Arterial inflow goes on Arterial haemorrhage occurs
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Excessive pressure on eyes > than Arterial pressure Arterial inflow Ischemia to Retina

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Eye injury

Corneal abrasion due to physical injury occurs Taping of eyelids after instillation of artificial tears will prevent this

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Eye injury

Horse shoe rest for the head Note no pressure on the eyes

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Summary

All the team members should be familiar with possible risks to maintain patient safety

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Summary
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Make sure the OR table will permit the position Gather all positioning accessories before the patient arrives to OR Check with the anesthesia provider prior to moving the patient Provide the number of personnel needed Use slow movements & do not drag the patient. Move with a team approach
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Summary
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Pad all bony points adequately Protect all superficial nerves Ensure that the legs are not crossed to prevent pressure on nerves or blood vessels Secure the patient to OR bed properly to prevent slipping Maintain patient dignity & privacy by avoiding unnecessary exposure
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