presentation the topic describe the complications of prone position for patient under gerneral anesthesia undergoing surgery .

1. Complications of Prone Position For Patient under General Anesthesia
Mohamed Khelifa, AT, CPSO
Al Wakra Hospital – June 2022

2. I have no conflict of interest to declare regarding this presentation

3. The prone position has been described, used, and developed as a result of the requirement for
surgical access. However, pioneers of spinal surgery in the 1930s and 1940s were hampered
because no effort was made to avoid abdominal compression when positioning the patient.
Prone position (PP) has been used since the 1970s to treat severe hypoxemia
in patients with ARDS because of its effectiveness in improving gas exchange.
Historical development

4. INTRODUCTION
• Prone positioning is a common position used for access to the posterior head, neck, and spine
during spinal surgery Access to the retroperitoneum and upper urinary tracts and access to posterior
structures when required during plastic surgery.
• Prone positioning is associated with several important and potentially catastrophic complications which can
result in permanent disability.
• Complications include hemodynamic changes resulting in hypoperfusion, a range of ophthalmologic
conditions, central nervous system lesions, peripheral nerve compression injuries, compartment syndrome,
and pressure ulcers.
• Other complications include airway swelling and peripheral arterial compression.

5. Benefits of Prone Positioning
 Improve V/Q mismatch
 Increased ventilation independent areas
 Decreases physiologic shunt
 Improved ventilation in areas where perfusion remains the same
 Decreases compression/Increases FRC Cardiac
 Prevent ventilator-associated lung injury
 Enhances mobilization of secretions

6. Anesthesia for Prone Position
 Induction and Intubation in supine position
 Turn prone as a single unit requiring at least 4 people
 Neck should be in a neutral position
 Head may be turned to the side not exceeding the patient’s normal range of motion or
face down On a cushioned holder
 Arms should be at the sides in a comfortable position with the elbow flexed (avoiding
excessive Adduction at the shoulder)
 Chest should rest on parallel rolls (foams) or special supports (frame)to facilitate
ventilation
 Check oral endotracheal tube, ckt, and other attachments.
 Check breath sounds bilaterally

7. Complications
Complications that occur from poor positioning cause morbidity, and in some cases mortality.
Knowledge of the potential problems allows the practitioner to pay particular attention to
risk
1- Pressure Injuries
Pressure injuries are caused either directly by pressure on the affected tissue or directly
By pressure to the vascular supply and drainage of the injured area.
Pressure ulcer at the edge of
the endotracheal tube holder

8. Facial pressure ulcer from use of the Andrews frame
An unusual cause of unilateral facial
injuries caused by horseshoe ...
Pressure ulcer appearing to reflect
the shape of the endotracheal tube
holder

9. Andrews frame (A) Wilson frame (B)
Jackson Table
Montreal Mattress

10. ALWAKRA HOSPITAL
Head positioning cushion

11. 2- Ophthalmic Complications
o Ophthalmic complications range from abrasions to devastating postoperative visual loss.
o There are two mechanisms, with differing aetiology. The direct pressure on the eye can lead to central retinal artery
whereas ischaemic optic neuropathy can occur without any pressure on the globe or orbit
Periorbital Edema
Periorbital Edema
Corneal Abrasion

12. 3- Peripheral Nervous System
Injuries to the peripheral nervous system are one of the most common complications and
all superficial peripheral nerves should be considered at risk. It is widely believed that poor positioning
and compression or stretch of the nerve within its narrow bony canal (ulnar nerve
at the elbow) or from external compression (common peroneal nerve by straps/pads below the knee) is
responsible for the development of neuropathy.

13. 4- Central Nervous System
it is also important to take care not to over-extend or flex the cervical spine. Those patients
with an unstable spine should be log rolled and it is our practice (once the airway has been
secured) to transfer care of the head and neck during positioning to the surgeon in this
group.

14. 5- Accidental Extubation
Accidental tracheal extubation with the patient in the prone position can be a catastrophic
complication. Even if tracheal intubation was performed easily in the supine position, this
represents a challenging airway scenario for several reasons. First, there is less time to re-establish
the airway because oxygen reserves may be limited, particularly if the FiO2 has been below 0.6).
Second, anaesthesiologists are not accustomed to performing bag-mask ventilation or attempting
airway manoeuvres with the patient prone.

15. 6 - Cardiac Arrest
Cardiac arrest in the prone position is a rare event. case reports have described
successful resuscitation and defibrillation in the prone position. This has allowed
immediate commencement of cardiopulmonary resuscitation while preparing to turn
supine. Chest compressions have been performed using several methods including
placing a hand over each scapula, compressions over the thoracic spine with or without
counter-pressure on the sternum, or open cardiac compressions if surgery already
involves a thoracotomy.

16. Practicalities
Six members of staff are needed to position a patient prone: one person (usually the anesthetist, except in
of unstable spine injury) at the head, one moving the feet, and two on either side of the patient. Additional
members of staff may be required for obese patients or patients with unstable spines requiring ‘log-rolling’.
Alternatively, specialized equipment such as the Jackson table can be used to turn the patient, see the
our practice to disconnect monitoring, infusions, and the breathing system while turning the patient to
the risk of accidentally dislodging lines or the tracheal tube (TT). As soon as the patient is prone all lines,
monitoring, and the breathing circuit are reconnected.

18. Checklist

19. Some Reported Cases

20. Prone Position and Complications (some reported cases)
 Visual Loss ( bilateral & unilateral)
 Posterior ischemic optic neuropathy
 Retinal artery occlusion
 Paraplegia
 Ischemic orbital compartment syndrome
 Acute glaucoma
 Macroglossia
 Anterior thigh compartment syndrome
 Avascular necrosis of femoral head
 Thoracic outlet syndrome
 Coronary vasospasm
 Hepatic infarction
 Rhabdomyolysis
 Quadriplegia
 Atlantoaxial dislocation
 Intracerebral hemorrhage
 Thromboembolic event
 Subconjunctival hemorrhage
 Shoulder dislocation
 Bilateral occipital lobe infarct
 Bifrontal epidural hematoma
 Prolonged hypotension
 Acute mesenteric ischemia
 Brachial plexopathy

21.  Peripheral neuropathies
 Nerve entrapment syndromes e.g. carpal tunnel
 Diabetes mellitus
 Osteoarthritis, Rheumatoid arthritis
 Pre-existing decubiti
 Venous stasis
 Previous traumatic injury, fractures
 Advanced age
 Alcohol abuse
 Malnutrition
 Vitamin deficiencies
 Corticosteroid use
 Contractures
 Morbid obesity
 Hypothyroidism
 Renal disease
Complications Risk Factors

23. Prone Position Protocol
Use the best practices when implementing prone positioning of patients with ARDS
 Obtain an order for prone positioning
 Assess the hemodynamic status and oxygenation to determine his or her eligibility
 Administer sedation and neuromuscular blocking agents as ordered.
 Provide eye care/lubrication, and tape eyelids if indicated.
 Ensure that the patient’s tongue is inside the mouth, insert a bite block if needed, and provide oral
care as needed
 Secure the airway/endotracheal tube and suction as necessary.
 Perform anterior skincare, and place hydrocolloid dressing on bony prominences, chin, and
forehead.
 Position the patient’s face away from the ventilator to prevent tube kinking, and reposition the
patient’s head hourly to prevent skin breakdown.
 Empty any drainage bag
 Place ECG electrodes on the patient’s posterior chest.
 Assign interprofessional team members to reposition responsibilities.
 Monitor the patient’s response to prone positioning.
 Obtain arterial blood gas.

24. Aesthetic Problems for Prone Position
I –AIRWAY
- ETT tube kinking or dislodgement
- edema of the upper airway in prolonged cases
II – BLOOD VESSELS
- Arterial or veinous occlusion of the upper extremity
- Kinking of the femoral vein with marked flexion of the hips
- Augmentation of abdominal pressure.
- Augmentation of epidural veinous pressure can cause bleeding because frames elevates.

25. III – PRESSURE NECROSIS
- Nose
- Ear
- Forehead
- Breast ( females)
- Genitals ( males)
IV – MONITORS
- The disconnection of the monitors is hard to avoid, it should be managed carefully

26. V -
NERVES
- Brachial plexus stretch or compression.
- Ulnar nerf N compression: pressure of the olecranon
- Lateral femoral cutaneous N trauma: pressure over the iliac crest
VI – HEAD & NECK
- Gross hyperflexion or hyperextension of the neck .
- External pressure over the eyes: retinal injury.
- Lack of lubrication or coverage of eyes.
- Head rest may cause pressure injury of supraorbital N
- Excessive rotation of the neck can cause brachial plexus problems.
- L- Spine excessive lordosis may lead to neurologic injury.

27.  40/M w/h/o C-spine whiplash injury s/p C4-5-6
 discectomy underwent excision of soft tissue mass in the prone position under GA
 C-spine stabilization, awake fiber optic intubation, horseshoe headrest
 PACU c/o dizziness, headache, painful numbness of the right face, slurred speech, and myoclonic,
spasms of left side extremities
 MRA Rt vertebral artery stenosis? Lateral medullary syndrome
 Causes excessive rotation or extension of the head during positioning, hypoperfusion under GA?
exacerbated vertebral arterial insufficiency.
Case Report
Thoracic disc herniation: An
unusual complication after
prone positioning in spinal
surgery

28. Conclusion
Increased age, elevated body mass index, the presence of comorbidities, and the long duration of surgery
to be the most important risk factors for complications associated
with prone positioning. We recommend a structured team approach and careful selection of equipment
to the patient and surgery. The systematic use of checklists is recommended to guide operating room teams
reduce prone to position-related complications. Anaesthesiologists should be prepared to manage major
intraoperative emergencies (accidental extubation) and anticipate postoperative complications ( airway
and visual loss).

29. Summary
•Discuss the indication of proning
•Increased awareness of the physiological effects proning has on patients.
•Identified the contraindications to proning
•Injury can occur to all organ systems (including the eyes), due to direct or indirect
pressure effects.
•For most cases, a securely fastened tracheal tube is the airway device of choice.
•In the event of a cardiac arrest, chest compressions and defibrillation can be commenced
in the prone position.
•All the team members should be familiar with possible risks to maintain patient safety.
• Check with the anaesthesia provider to move the patient.
•Use slow movements and do not drag the patient, move with a team approach.

30. objectives
1. Identify the various types of equipment used in prone positioning, including their indications,
advantage and disadvantages.
2. Understand the potential complications that can occur with prone positioning and describe
techniques to prevent or manage them.
3. Formulate a strategy for planned extubating after prolonged prone positioning.
4. Describe the management of accidental extubating during prone positioning.
5. Discuss strategies to improve the safety of patients undergoing surgery in prone positions.

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References

32. Thank You
1- Anesthesia for trauma patient
2- Pediatric Anesthesia
3- Postoperative Pain Management
4- Pediatric Cardiac Arrest
5- Anesthesia for Liver Transplant
6- Antibiotic Prophylaxis for surgical procedures
7- High Alert Medication
8- Arterial & Central lines Monitoring
9- Patient Safety in Anesthesia
10- Anesthesia Concern for Covid-19 Patient
11- Presentation of new airway Management device (TUBAIR) in innovation symposium
12- Complications of Prone Position under GA
For Attending My 12 Presentations in HMC