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

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

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

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

Goal of surgical positioning is to facilitate surgeon’s technical approach while balancing risk factors

All surgical positions have position-related risks

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

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

Erect position to Supine position Cardiac output ↑ on assuming supine position Venous blood from lower body ↓ flows back To heart ↓ Stretches atrial wall ↓ (Laplace’s law) Stroke volume ↑ ↓ ↑ blood pressure (clinically normal BP observed)

Cardiac output ↑ on assuming supine position

Venous blood from lower body

↓ flows back

To heart

↓

Stretches atrial wall

↓ (Laplace’s law)

Stroke volume ↑

↓

↑ blood pressure

(clinically normal BP observed)

Baroreceptors in Aorta Baroreceptors in Carotid ↓ via ↓ via sinus Vagus nerve Glossopharyngeal nerve Medulla Oblongata ↓ efferent ↑ Parasympathetic activity ↓ ↓ HR ↓SV ↓Contractility ↓ Little change in BP noted

Baroreceptors in Aorta Baroreceptors in Carotid

↓ via ↓ via sinus

Vagus nerve Glossopharyngeal nerve

Medulla Oblongata

↓ efferent

↑ Parasympathetic activity

↓

↓ HR ↓SV ↓Contractility

↓

Little change in BP noted

Erect posture effect on pulmonary system Abdominal contents & diaphragm move caudally FRC ↑ TLC ↑

Abdominal contents & diaphragm move caudally

FRC ↑ TLC ↑

Supine posture effect on pulmonary system Abdominal contents move cephalad FRC ↓ TLC ↓

Abdominal contents move cephalad

FRC ↓ TLC ↓

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

Commonest position for most of the surgeries

Care should be exercised to prevent injuries to the anesthetized patient

Supine position – Pressure points

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

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

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

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

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

Lithotomy positioning - I

Lithotomy positioning - II

Final lithotomy position

Lithotomy position with stirrups

Lithotomy position

Urology -- Lithotomy position

Lithotomy position

Various types of Lithotomy stirrups

Lithotomy position

Nerve injuries in lithotomy Peroneal nerve injury Saphenous nerve injury Femoral nerve injury Obturator nerve injury

Peroneal nerve injury

Saphenous nerve injury

Femoral nerve injury

Obturator nerve injury

Lithotomy position – Nerve injuries Peroneal nerve Saphenous nerve Femoral nerve Obturator nerve

Lithotomy – nerve injuries

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

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

Lithotomy position - problems

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

Long duration of lithotomy position

Tightening of leg straps

Dorsi-flexion of ankle

Surgeon leaning on suspended leg for long duration

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

Compartment syndrome of hand occurs when hand is tucked under the buttocks & OR table

Extension of upper limb > 90* causes traction of brachial plexus

Chemical burns in lithotomy position Rare fortunately Pooling of preparation solutions at buttock & lower back causes chemical burns

Rare fortunately

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

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

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

Lateral position

Lateral position

Lateral position

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

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

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

This position is used for surgeries on the kidney & ureters

Kidney bridge is elevated & this opens up the retro pelvic space for optimal exposure

Lateral position with kidney bridge

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 Patient looks like he is trying to look at the floor

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

Patient looks like he is trying to look at the floor

Lateral oblique position Surgeon Assistant

Lateral oblique position Surgeon Assistant

Lateral oblique position Surgeon Assistant

Lateral oblique position

Lateral oblique position

Lateral oblique position

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

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

Prone position Lumbar Laminectomy Spinal instrumentation Steffi’s plating Harrington’s rod Pilonidal sinus excision

Lumbar Laminectomy

Spinal instrumentation

Steffi’s plating

Harrington’s rod

Pilonidal sinus excision

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

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

Prone position – induction on trolley

Prone position Ist stage

Prone position

Prone position

Prone position

Prone position with laminectomy frame - pressure points

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

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

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

↑ CVP

↑ ICP

↑ IOP

↑ myocardial work

↑ pulmonary venous pressure

↓ pulmonary compliance

↓ FRC

Swelling of face, eyelids, conjunctiva & tongue

observed in long surgeries

Trendlenburg position

Reverse Trenlenberg’s position This is the opposite of Trenlenberg’s 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

This is the opposite of Trenlenberg’s 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

Reverse Trenlenberg position

Jack knife position ( Kraske ) Used for anal surgeries, pilonidal sinus excision Places patient prone with head & feet at a lower level

Used for anal surgeries, pilonidal sinus excision

Places patient prone with head & feet at a lower level

Jack knife position

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

Further exaggeration of knee-chest position

Used for sigmoidoscopies or lumbar laminectomies

Severe hypotension is seen due to pooling of blood in the legs

Knee chest position – pressure points

Orthopedic surgeries positions Orthopedic fracture table – Wattson-Jone’s 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

Orthopedic fracture table – Wattson-Jone’s

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

Orthopedic surgeries needing Wattson-Jone’s table # shaft femur for Interlocking DHS with plate Inter-trocanteric # femur

# shaft femur for Interlocking

DHS with plate

Inter-trocanteric # femur

Wattson Jone’s table used for Ortho surgery

Wattson Jone’s table used for Ortho surgery

Lateral position on Wattson Jone’s table

Problems with this position Brachial plexus injury Due to > than 90* extension of the upper limb Lower extremity compartment syndrome Due to long surgeries & compression Pudendal nerve injury Due to pressure of the perineal post

Brachial plexus injury

Due to > than 90* extension of the upper limb

Lower extremity compartment syndrome

Due to long surgeries & compression

Pudendal nerve injury

Due to pressure of the perineal post

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

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

Beach chair position for shoulder surgery (Semi Fowler position)

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

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

Sitting position - Neuro surgery

Sitting position – pressure points

Sitting position

Relative contra-indication to sitting position V-P shunt in 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 enter systemic circulation

V-P shunt in 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 enter systemic circulation

Problems in sitting position Venous air embolism Hypotension (prevented by stockings) Arms – if not well supported cause brachial-plexus stretching

Venous air embolism

Hypotension (prevented by stockings)

Arms – if not well supported cause brachial-plexus stretching

Venous air-embolism Most feared complication in sitting position With subsequent PAE to the brain

Most feared complication in sitting position

With subsequent PAE to the brain

Air embolism Right atrium with air embolus CVP catheter in situ

Right atrium with air embolus

CVP catheter in situ

Air – embolism monitor warnings

Mandatory monitoring EKG BP SpO2 EtCO2 Doppler CVP Pulmonary artery catheter

EKG

BP

SpO2

EtCO2

Doppler

CVP

Pulmonary artery catheter

Pre-cordial Doppler device Most advocated monitoring Reasonably priced Relatively easy to use Non-invasive Sensitive Sounds heard both by surgeons & anesthesiologist

Most advocated monitoring

Reasonably priced

Relatively easy to use

Non-invasive

Sensitive

Sounds heard both by surgeons & anesthesiologist

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

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

Types of nerve injury Neuropraxia Axonotomasis Neurotomasis

Neuropraxia

Axonotomasis

Neurotomasis

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

Occurs with loss of function

Without demonstrable anatomic injury

Related to positioning under anesthesia

Recovery complete in 6 weeks

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

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

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

Results in axon, sheath & connective tissue disruption

Leads to degeneration of axon distal to injury

Course of Upper limb nerves

Brachial plexus in the axilla

Coarse of nerves in thigh

Coarse of nerves in leg

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

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

Ulnar nerve injury Pronated arm Unpadded elbow Supinated arm Elbow padded Ulnar nerve pressure

Ulnar nerve @ cubital fossa

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

Excessive pressure on eyes Excessive pressure on eyes

↓ > than

↓ more than Arterial pressure

↓

Venous pressure Arterial inflow ↓

↓ ↓

Venous collapse Ischemia to Retina

↓

Arterial inflow goes on

↓

Arterial haemorrhage occurs

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

Corneal abrasion due to physical injury occurs

Taping of eyelids after instillation of artificial tears will prevent this

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

Horse shoe rest for the head

Note no pressure on the eyes

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

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

Summary 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

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

Summary 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

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

Thank you