Patient Positioning


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Patient Positioning

  1. 1. Patient Positioning Dr. Shailendra.V.L. Specialist in Anesthesia, Al Bukariya general hospital.
  2. 2. Introduction <ul><li>Important to know the various implications of patient positioning during surgery </li></ul><ul><li>Because of the various physiological effects it exerts on the systems </li></ul><ul><li>In the last 2 decades newer surgical techniques developed due to advances </li></ul><ul><ul><li>In electronics </li></ul></ul><ul><ul><li>In technology as a whole </li></ul></ul><ul><ul><li>Better understanding of physiology </li></ul></ul>
  3. 3. Goal of positioning <ul><li>Goal of surgical positioning is to facilitate surgeon’s technical approach while balancing risk factors </li></ul><ul><li>All surgical positions have position-related risks </li></ul>
  4. 4. Physiologic effects of change from vertical to horizontal position <ul><li>Body responses to alteration of positions is due to gravity </li></ul><ul><li>Effects of Gravity: </li></ul><ul><ul><li>On blood in venous / arterial / pulmonary systems </li></ul></ul><ul><ul><li>On pulmonary mechanics </li></ul></ul><ul><ul><li>On pulmonary perfusion </li></ul></ul>
  5. 5. Erect position to Supine position <ul><li>Cardiac output ↑ on assuming supine position </li></ul><ul><li>Venous blood from lower body </li></ul><ul><li>↓ flows back </li></ul><ul><li>To heart </li></ul><ul><li>↓ </li></ul><ul><li>Stretches atrial wall </li></ul><ul><li>↓ (Laplace’s law) </li></ul><ul><li>Stroke volume ↑ </li></ul><ul><li>↓ </li></ul><ul><li>↑ blood pressure </li></ul><ul><li>(clinically normal BP observed) </li></ul>
  6. 6. <ul><li>Baroreceptors in Aorta Baroreceptors in Carotid </li></ul><ul><li>↓ via ↓ via sinus </li></ul><ul><li>Vagus nerve Glossopharyngeal nerve </li></ul><ul><li>Medulla Oblongata </li></ul><ul><li> ↓ efferent </li></ul><ul><li>↑ Parasympathetic activity </li></ul><ul><li>↓ </li></ul><ul><li>↓ HR ↓SV ↓Contractility </li></ul><ul><li>↓ </li></ul><ul><li>Little change in BP noted </li></ul>
  7. 7. Erect posture effect on pulmonary system <ul><li>Abdominal contents & diaphragm move caudally </li></ul><ul><li>FRC ↑ TLC ↑ </li></ul>
  8. 8. Supine posture effect on pulmonary system <ul><li>Abdominal contents move cephalad </li></ul><ul><li>FRC ↓ TLC ↓ </li></ul>
  9. 9. Supine position <ul><li>Commonest position for most of the surgeries </li></ul><ul><li>Care should be exercised to prevent injuries to the anesthetized patient </li></ul>
  10. 10. Supine position – Pressure points
  11. 11. Arm tucking in supine position <ul><li>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 </li></ul>
  12. 12. Arm tucking Note the arms is tucked using draw sheet & arm is secured by the side of the patient
  13. 13. Lithotomy <ul><li>Used in gynecology & urology procedures </li></ul><ul><li>Elevation of legs promotes translocation of vascular volume centrally </li></ul><ul><li>Areas supporting weight of legs prone for nerve injury </li></ul><ul><li>Legs supported at knee & suspended by stirrups </li></ul>
  14. 14. Lithotomy positioning - I
  15. 15. Lithotomy positioning - II
  16. 16. Final lithotomy position
  17. 17. Lithotomy position with stirrups
  18. 18. Lithotomy position
  19. 19. Urology -- Lithotomy position
  20. 20. Lithotomy position
  21. 21. Various types of Lithotomy stirrups
  22. 22. Lithotomy position
  23. 23. Nerve injuries in lithotomy <ul><li>Peroneal nerve injury </li></ul><ul><li>Saphenous nerve injury </li></ul><ul><li>Femoral nerve injury </li></ul><ul><li>Obturator nerve injury </li></ul>
  24. 24. Lithotomy position – Nerve injuries Peroneal nerve Saphenous nerve Femoral nerve Obturator nerve
  25. 25. Lithotomy – nerve injuries
  26. 26. Nerve injuries in lithotomy <ul><li>Peroneal nerve injury: </li></ul><ul><ul><li>Pressure of head of fibula by bar or support structures compresses nerve </li></ul></ul><ul><li>Saphenous nerve injury: </li></ul><ul><ul><li>Pressure on medial condyle of tibia compress nerve </li></ul></ul><ul><li>Femoral nerve injury: </li></ul><ul><ul><li>Due to angulation of thigh such that inguinal ligament is stretched & compresses nerve </li></ul></ul><ul><li>Obturator nerve injury: </li></ul><ul><ul><li>Due to greater degree of thigh flexion there is stretching of nerve as it exits the obturator foramen </li></ul></ul>
  27. 27. Lithotomy position - problems
  28. 28. Compartment syndrome in lower limbs during lithotomy position <ul><li>Long duration of lithotomy position </li></ul><ul><li>Tightening of leg straps </li></ul><ul><li>Dorsi-flexion of ankle </li></ul><ul><li>Surgeon leaning on suspended leg for long duration </li></ul>
  29. 29. Upper limb injury during lithotomy position <ul><li>Compartment syndrome of hand occurs when hand is tucked under the buttocks & OR table </li></ul><ul><li>Extension of upper limb > 90* causes traction of brachial plexus </li></ul>
  30. 30. Chemical burns in lithotomy position <ul><li>Rare fortunately </li></ul><ul><li>Pooling of preparation solutions at buttock & lower back causes chemical burns </li></ul>
  31. 31. Lateral position <ul><li>A pad placed under the head </li></ul><ul><li>Arm perpendicular to torso, either on pillow or an over arm rest </li></ul><ul><li>Pillow between the legs </li></ul><ul><li>Arm taped on this position </li></ul><ul><li>Care taken that tape does not press ulnar nerve @ elbow or radial nerve @ radial groove </li></ul>
  32. 32. Lateral position
  33. 33. Lateral position
  34. 34. Lateral position
  35. 35. Higher chest exposure in lateral position <ul><li>Arm kept in more anterior plane to body to prevent stretching of brachial plexus </li></ul><ul><li>Lower chest supported by axillary role </li></ul><ul><ul><li>Supports weight of thorax </li></ul></ul><ul><ul><li>Prevents compression of shoulder & axilla </li></ul></ul><ul><ul><li>Prevents brachial plexus injury in axilla </li></ul></ul><ul><li>Palpate Radial artery of dependent arm to ensure there is no compression </li></ul>
  36. 36. Lateral position with kidney bridge <ul><li>This position is used for surgeries on the kidney & ureters </li></ul><ul><li>Kidney bridge is elevated & this opens up the retro pelvic space for optimal exposure </li></ul>
  37. 37. Lateral position with kidney bridge
  38. 38. Lateral oblique Three quarters prone position <ul><li>Used for exposure of posterior cranial fossa </li></ul><ul><li>Head rotated from supine to lateral </li></ul><ul><li>Head holder pins are inserted </li></ul><ul><li>Upper leg is bought forward & flexed slightly </li></ul><ul><li>Lower leg is left straight </li></ul><ul><li>Axillary role placed under chest to support weight of body </li></ul><ul><li>Lower shoulder bought to forward edge of bed or just slightly over it </li></ul><ul><li>Upper arm placed downward near the side comfortably </li></ul><ul><li>Patient looks like he is trying to look at the floor </li></ul>
  39. 39. Lateral oblique position Surgeon Assistant
  40. 40. Lateral oblique position Surgeon Assistant
  41. 41. Lateral oblique position Surgeon Assistant
  42. 42. Lateral oblique position
  43. 43. Lateral oblique position
  44. 44. Lateral oblique position
  45. 45. Problems in lateral oblique position <ul><li>In obese patients difficulty in placing lower arm below torso </li></ul><ul><li>Cause considerable weight on humeral head & acromion </li></ul><ul><li>Lower breast can get compressed – pressure on nipple & areola </li></ul><ul><li>Extreme neck flexion cause cervical spinal cord hypo-perfusion </li></ul><ul><li>ECG electrodes can cause pressure necrosis </li></ul>
  46. 46. Prone position <ul><li>Lumbar Laminectomy </li></ul><ul><li>Spinal instrumentation </li></ul><ul><ul><li>Steffi’s plating </li></ul></ul><ul><ul><li>Harrington’s rod </li></ul></ul><ul><li>Pilonidal sinus excision </li></ul>
  47. 47. Prone position - problems <ul><li>Careful positioning from supine position </li></ul><ul><li>Prevent pressure on abdomen </li></ul><ul><li>Prevent pressure on eyes </li></ul><ul><li>Pillows to rest the lower limbs </li></ul><ul><li>Prevent pressure on male external genitalia </li></ul>
  48. 48. Prone position – induction on trolley
  49. 49. Prone position Ist stage
  50. 50. Prone position
  51. 51. Prone position
  52. 52. Prone position
  53. 53. Prone position with laminectomy frame - pressure points
  54. 54. Trendlenberg’ s position <ul><li>Modification of supine position </li></ul><ul><li>Places head down along with the whole body </li></ul><ul><li>Advantages of this position: </li></ul><ul><ul><li>Moves viscera cephalad </li></ul></ul><ul><ul><li>Helpful in lower abdominal surgeries </li></ul></ul><ul><ul><li>To ↑ venous return after spinal anesthesia </li></ul></ul><ul><ul><li>To ↑ central blood volume to facilitate central vein cannulation </li></ul></ul><ul><ul><li>To minimize aspiration during regurgitation </li></ul></ul>
  55. 55. Effects of Trenlenberg’ s position <ul><li>↑ CVP </li></ul><ul><li>↑ ICP </li></ul><ul><li>↑ IOP </li></ul><ul><li>↑ myocardial work </li></ul><ul><li>↑ pulmonary venous pressure </li></ul><ul><li>↓ pulmonary compliance </li></ul><ul><li>↓ FRC </li></ul><ul><li>Swelling of face, eyelids, conjunctiva & tongue </li></ul><ul><li>observed in long surgeries </li></ul>
  56. 56. Trendlenburg position
  57. 57. Reverse Trenlenberg’s position <ul><li>This is the opposite of Trenlenberg’s position </li></ul><ul><li>This position places head end up & feet down </li></ul><ul><li>This position helps in caudal movement of abdominal contents </li></ul><ul><li>Used in upper abdominal laparoscopic surgeries – Lap gastric banding </li></ul><ul><li>Causes venous pooling in lower limbs </li></ul><ul><li>To prevent DVT stockings is a must </li></ul>
  58. 58. Reverse Trenlenberg position
  59. 59. Jack knife position ( Kraske ) <ul><li>Used for anal surgeries, pilonidal sinus excision </li></ul><ul><li>Places patient prone with head & feet at a lower level </li></ul>
  60. 60. Jack knife position
  61. 61. Knee chest position <ul><li>Further exaggeration of knee-chest position </li></ul><ul><li>Used for sigmoidoscopies or lumbar laminectomies </li></ul><ul><li>Severe hypotension is seen due to pooling of blood in the legs </li></ul>
  62. 62. Knee chest position – pressure points
  63. 63. Orthopedic surgeries positions <ul><li>Orthopedic fracture table – Wattson-Jone’s </li></ul><ul><ul><li>Body section to support head & thorax </li></ul></ul><ul><ul><li>Sacral plate for pelvis </li></ul></ul><ul><ul><li>Perineal post </li></ul></ul><ul><ul><li>Adjustable foot plates </li></ul></ul><ul><li>Table maintains traction of the extremity </li></ul><ul><li>Allows surgical & fluroscopic access </li></ul><ul><li>Anesthesia induced & then the patients are positioned on this table (pain) </li></ul><ul><li>Arm on # side placed so that it will not interfere with surgical access </li></ul>
  64. 64. Orthopedic surgeries needing Wattson-Jone’s table <ul><li># shaft femur for Interlocking </li></ul><ul><li>DHS with plate </li></ul><ul><li>Inter-trocanteric # femur </li></ul>
  65. 65. Wattson Jone’s table used for Ortho surgery
  66. 66. Wattson Jone’s table used for Ortho surgery
  67. 67. Lateral position on Wattson Jone’s table
  68. 68. Problems with this position <ul><li>Brachial plexus injury </li></ul><ul><ul><li>Due to > than 90* extension of the upper limb </li></ul></ul><ul><li>Lower extremity compartment syndrome </li></ul><ul><ul><li>Due to long surgeries & compression </li></ul></ul><ul><li>Pudendal nerve injury </li></ul><ul><ul><li>Due to pressure of the perineal post </li></ul></ul>
  69. 69. Positions for shoulder surgery <ul><li>Beach chair / barber chair / semi-recumbent position </li></ul><ul><li>Provides both anterior & posterior access to shoulder </li></ul><ul><li>Provides freely mobile upper limb </li></ul><ul><li>Endotraheal tube secured well to prevent accidental extubation </li></ul>
  70. 70. Beach chair position for shoulder surgery (Semi Fowler position)
  71. 71. Sitting position--Fowler position <ul><li>For posterior cranial fossa position </li></ul><ul><li>Better surgical exposure </li></ul><ul><li>Less tissue retraction & damage </li></ul><ul><li>Less bleeding </li></ul><ul><li>Less cranial nerve damage </li></ul><ul><li>More complete resection of lesion </li></ul><ul><li>Ready access to airway, chest & extremities </li></ul><ul><li>Modern monitoring gives early warning of venous air-embolism </li></ul>
  72. 72. Sitting position - Neuro surgery
  73. 73. Sitting position – pressure points
  74. 74. Sitting position
  75. 75. Relative contra-indication to sitting position <ul><li>V-P shunt in position </li></ul><ul><li>Cerebral-ischemia upright awake </li></ul><ul><li>Patent foramen ovale & R –L shunt </li></ul><ul><li>Cardiac instability </li></ul><ul><li>Extremes of ages </li></ul><ul><li>Left AP < RAP ------- Platypnea –Orthodeoxia </li></ul><ul><ul><li>Patient becomes deoxygenated on assuming erect position </li></ul></ul><ul><ul><li>Arterial gradients reverses on assuming erect position </li></ul></ul><ul><ul><li>These patients open up foramen ovale & VAE can enter systemic circulation </li></ul></ul>
  76. 76. Problems in sitting position <ul><li>Venous air embolism </li></ul><ul><li>Hypotension (prevented by stockings) </li></ul><ul><li>Arms – if not well supported cause brachial-plexus stretching </li></ul>
  77. 77. Venous air-embolism <ul><li>Most feared complication in sitting position </li></ul><ul><li>With subsequent PAE to the brain </li></ul>
  78. 78. Air embolism <ul><li>Right atrium with air embolus </li></ul><ul><li>CVP catheter in situ </li></ul>
  79. 79. Air – embolism monitor warnings
  80. 80. Mandatory monitoring <ul><li>EKG </li></ul><ul><li>BP </li></ul><ul><li>SpO2 </li></ul><ul><li>EtCO2 </li></ul><ul><li>Doppler </li></ul><ul><li>CVP </li></ul><ul><li>Pulmonary artery catheter </li></ul>
  81. 81. Pre-cordial Doppler device <ul><li>Most advocated monitoring </li></ul><ul><li>Reasonably priced </li></ul><ul><li>Relatively easy to use </li></ul><ul><li>Non-invasive </li></ul><ul><li>Sensitive </li></ul><ul><li>Sounds heard both by surgeons & anesthesiologist </li></ul>
  82. 82. Mechanism of peripheral nerve injury <ul><li>2 basic forces impairing nerve function </li></ul><ul><ul><li>Nerves that course superficially for long distances are prone for stretch injury </li></ul></ul><ul><ul><li>Nerve that pass over bony structures over small area prone for compression </li></ul></ul><ul><ul><li>Final result – nerve ischemia – nerve injury </li></ul></ul><ul><ul><li>Ischemia > 30 minutes result in nerve palsy </li></ul></ul>
  83. 83. Types of nerve injury <ul><li>Neuropraxia </li></ul><ul><li>Axonotomasis </li></ul><ul><li>Neurotomasis </li></ul>
  84. 84. Neuropraxia <ul><li>Occurs with loss of function </li></ul><ul><li>Without demonstrable anatomic injury </li></ul><ul><li>Related to positioning under anesthesia </li></ul><ul><li>Recovery complete in 6 weeks </li></ul>
  85. 85. Axonotomesis <ul><li>Occurs with anatomic disruption of axons but preservation of nerve sheath & connective tissue </li></ul><ul><li>Axon degenerates distal to lesion </li></ul><ul><li>Regenerates @1mm / day </li></ul><ul><li>Function gradually returns but in longer nerves of upper limb will take upto 1 year </li></ul><ul><li>Physical therapy helpful to prevent degeneration of joints & muscles </li></ul>
  86. 86. Neurometesis <ul><li>Results in axon, sheath & connective tissue disruption </li></ul><ul><li>Leads to degeneration of axon distal to injury </li></ul>
  87. 87. Course of Upper limb nerves
  88. 88. Brachial plexus in the axilla
  89. 89. Coarse of nerves in thigh
  90. 90. Coarse of nerves in leg
  91. 91. Cubital-tunnel external compression syndrome <ul><li>Ulnar nerve passes through cubital tunnel of elbow </li></ul><ul><li>Forearm pronated will cause compression of ulnar nerve </li></ul><ul><li>Flexion @ elbow > 90* tenses arcuate ligament & reduces the tunnel size & compress nerve </li></ul>
  92. 92. Ulnar nerve injury Pronated arm Unpadded elbow Supinated arm Elbow padded Ulnar nerve pressure
  93. 93. Ulnar nerve @ cubital fossa
  94. 94. Eye injury <ul><li>Excessive pressure on eyes Excessive pressure on eyes </li></ul><ul><li> ↓ > than </li></ul><ul><li>↓ more than Arterial pressure </li></ul><ul><li>↓ </li></ul><ul><li>Venous pressure Arterial inflow ↓ </li></ul><ul><li>↓ ↓ </li></ul><ul><li>Venous collapse Ischemia to Retina </li></ul><ul><li>↓ </li></ul><ul><li>Arterial inflow goes on </li></ul><ul><li>↓ </li></ul><ul><li>Arterial haemorrhage occurs </li></ul>
  95. 95. Eye injury <ul><li>Corneal abrasion due to physical injury occurs </li></ul><ul><li>Taping of eyelids after instillation of artificial tears will prevent this </li></ul>
  96. 96. Eye injury <ul><li>Horse shoe rest for the head </li></ul><ul><li>Note no pressure on the eyes </li></ul>
  97. 97. Summary <ul><li>All the team members should be familiar with possible risks to maintain patient safety </li></ul>
  98. 98. Summary <ul><li>Make sure the OR table will permit the position </li></ul><ul><li>Gather all positioning accessories before the patient arrives to OR </li></ul><ul><li>Check with the anesthesia provider prior to moving the patient </li></ul><ul><li>Provide the number of personnel needed </li></ul><ul><li>Use slow movements & do not drag the patient. Move with a team approach </li></ul>
  99. 99. Summary <ul><li>Pad all bony points adequately </li></ul><ul><li>Protect all superficial nerves </li></ul><ul><li>Ensure that the legs are not crossed to prevent pressure on nerves or blood vessels </li></ul><ul><li>Secure the patient to OR bed properly to prevent slipping </li></ul><ul><li>Maintain patient dignity & privacy by avoiding unnecessary exposure </li></ul>
  100. 100. Thank you