The document provides a comprehensive overview of patient positioning during surgical procedures, emphasizing the responsibility of the medical team to ensure optimal positioning that balances surgical needs and patient safety. It details various positioning strategies, associated physiological changes, potential complications, and best practices to prevent adverse outcomes such as nerve injuries and pressure sores. Key positions discussed include supine, lithotomy, lateral, prone, and sitting, along with considerations for padding and support to maintain patient comfort and safety.

1. PATIENT
POSITIONING
PGI Ivan Bandiola

2. ● Patient positioning is a substantial responsibility that requires the
coordination of the entire medical team. A balance between optimal
surgical positioning and patient well-being is required.
● a compromise between what the patient can tolerate and what the
surgical team requires
● It is important to adapt an optimal positioning as it can prevent adverse
patient outcomes
○ May cause tissue damage
■ Stretching nerves to 5% greater than normal resting length can
lead to ischemia
Point pressure may reduce local blood flow
Use of padding - most common way to reduce point pressure
● Patient positioning and postural limitations should be assessed during the
preoperative evaluation
INTRODUCTION

3. ● To promote proper physiological alignment
● To maintain patient’s airway and avoid constriction on the chest cavity
● To minimize interference with circulation
● To gain optimum exposure to operative and anesthetic sites
● To protect skeletal and neuromuscular structures
● To provide comfort, stability, safety and dignity to the patient.
GOALS OF PROPER POSITIONING

4. ● The patient’s position during anesthesia care should be neutral-one that
would be well tolerated if the patient were awake and unsedated
● Weight-bearing surfaces and joints should be well padded and curvatures
including the lumbar spine should be supported
● The head should be in midline without substantial flexion and extension.
Eyes should be closed without external pressure.
● Tilting of the table before draping, using safety straps and prevention of
falls from the table are fundamental
GENERAL CONSIDERATIONS

5. We should assess the following prior to positioning of the patient:
● Duration of the surgery
● Surgeon’s preference of position
● Required position for procedure
● Anesthesia to be administered
● Patient’s risk factors (age, weight, skin condition, pre-existing conditions,
etc.)
● Basics of anatomy and physiology
ASSESSMENT

6. TABLE ACCESSORIES AND ATTACHMENTS

7. PHYSIOLOGICAL CHANGES RELATED TO
CHANGES IN BODY POSITION
● Most changes are related to gravitational effects on cardiovascular system
and respiratory system.
● Alterations in position redistribute blood within the venous, arterial and
pulmonary vasculature
● Pulmonary mechanics and pulmonary perfusion also vary with different
body positions

9. ● Anesthetized persons who are spontaneously breathing have a reduced TV,
FRC, and increased closing volume
● Positive pressure ventilation with muscle relaxation may ameliorate
ventilation-perfusion mismatches under GA by maintaining adequate minute
ventilation
● Gravity affects the preferential perfusion of the dependent portions of the
lung

11. SUPINE
POSITION

12. ● Most commonly used position for
surgeries.
● The head, neck and spine all retain
neutrality
● Arms can be abducted, adducted
but should be placed in as neutral
as possible
● When adducted arms are securely
placed next to the body. Abducted
arms are kept on arm boards
beside the table
● Attention should be given to pad
bony prominences
POSITIONING

13. ● Abduction should be limited to less
than 90 degrees to minimize brachial
plexus injury.
ARM POSITIONING
● When arms are adducted, they are
usually held alongside the body with
a “drawsheet” that passes under
the body.

14. ● Patient’s hips at the break of the
table.
● Reduces stress on back, hips and
knees as the are in flexed position.
● Sometimes this position is better
tolerated than full supine position
● Better venous drainage in lower
limb as they are slightly over the
level of the heart
● Abdominal wall tension is reduced,
as xiphoid to pubic distance is
reduced
LAWN CHAIR POSITION

15. ● Allows the access to the perineum,
medial thighs, genitalia and rectum.
● Positioned supine, hips and knees are
flexed with hips externally rotated and
soles facing each other.
● Care must be taken to minimize stress
and postoperative pain in the hips and
to prevent dislocation by appropriately
supporting the knees.
FROG LEG POSITION

16. ● Frequently used to improve exposure
during abdominal and laparoscopic
surgeries
● Position produces hemodynamic and
respiratory changes
● This position is often preferred during
central line placement to prevent air
embolism and to offset hypotension
by temporarily increasing venous
return.
● The cephalad movement of
diaphragm decreases FRC, thus,
decreasing pulmonary compliance.
TRENDELENBURG POSITION

17. ● This position increases CVP, ICP, IOP, and can have significant respiratory
consequences
○ In spontaneously ventilating patients, the work of breathing increases
○ In mechanically ventilated patients, airway pressures must be higher to
ensure adequate ventilation
● Prolonged head down can lead to swelling of face, conjunctiva, larynx and
tongue with an increased potential for post-operative upper airwair obstruction
● Care must be taken to prevent patients in steep head down positions form
slipping cephalad on the surgical table
● Shoulder braces are not recommended

18. ● Head up tilt is often employed to
facilitate upper abdominal
surgeries.
● The position of head above the
heart reduces cerebral perfusion
pressure and may also cause
systemic hypotension as venous
return decreases
REVERSE TRENDELENBURG POSITION

19. ● Greatest concerns are circulation and
pressure points.
● Most common nerve damages:
1. Brachial plexus: arm abduction >90
degrees.
2. Radial and ulnar: compression against the
OR bed, metal attachments
3. Peroneal and tibial: crossing of feet and
plantar flexion of ankles and feet
● Vulnerable bony prominences: due to
rubbing and sustained pressure (occiput,
spine, scapula, olecranon, sacrum,
calcaneus)
SUPINE CONCERNS

21. ● Pressure alopecia
○ Caused by ischemic hair follicles, us related to prolonged
immobilization of the head with its full weight falling on a limited area,
usually the occiput.
● Backache
○ May occur because the normal lordotic curvature is often lost during
GA with muscle relaxation or a neuraxial block
● Peripheral nerve injury
○ Brachial plexus injury, ulnar neuropathy, etc.
COMPLICATIONS

22. LITHOTOMY
POSITION

23. ● The classic lithotomy position is
frequently used during gynecologic,
rectal and urologic surgeries.
● The hips are flexed 80 to 100 degrees
from the trunk, and the legs are
abducted 30 to 45 degrees from the
midline.
● The knees are flexed until the lower
legs are parallel to the torso and
supports or stirrups hold the legs.
● The foot section of the table is
lowered or detached
POSITION

24. ● The lower extremities should be padded
to prevent compression against the
stirrups
● Initiation of the lithotomy position
requires coordinated positioning of the
lower extremities by two assistant to
avoid torsion of the lumbar spine. Both
the legs should braised together,
simultaneously flexing the hips and
knees
● After the surgery, the patient
must also be returned to the
same position in a
coordinated manner

25. ● The recommended position of the arms is
on armrests far from the table hinge
point.
● If the arms are on the surgical table
alongside the patient, then the hands and
fingers may lie near the open edge of the
lower section of the table.
● Crush injury of fingers may occur when
the foot of the table is raised.
ARM POSITIONING

26. ● Frequently used for procedures that
requires a vaginal or perineal approach
● The patient is in the supine position with
legs raised and abducted by stirrups
● Once the feet are positioned in the stirrups,
the foot-board is removed and the bottom
section of the bed is lowered.
HIGH LITHOTOMY POSITION

27. ● All the positioning techniques used in high
lithotomy apply.
● Placed in supine position with the legs
raised and abducted in crutch-like or full
lower leg support stirrups.
● The angle between the patient’s thigh and
trunk is not as acute as for the high
lithotomy position
● Used in vaginal procedures, perineal
access, transurethral instrumentation.
LOW LITHOTOMY POSITION

28. ● Transperineal access to the retropubic area
● The patient’s pelvis is flexed ventrally on the
spine
● The thighs almost forcibly flexed on the trunk
● The lower legs aimed skyward so they are out
of the way
● The long axis of the symphysis pubis almost
parallel to the floor
EXAGGERATED LITHOTOMY POSITION

29. STIRRUPS

30. ● When the legs are elevated, venous return increases, causing a transient
increase in cardiac output, central venous, intracranial pressure in otherwise
healthy patients
● The lithotomy position causes the abdominal visceral to displace the
diaphragm cephalad, reducing lung compliance and tidal volume
● The normal lordotic curvature of the lumbar spine is lost, potentially
aggravating any previous lower back pain.
LITHOTOMY CONCERNS

31. POTENTIAL NERVE
INJURIES

32. ● Rare complication caused by inadequate tissues perfusion that is associated with
the lithotomy position
● Local arterial pressure decreases 0.78 mmHg for each cm the leg is raised above
the right atrium
● Decompression fasciotomy -tissue pressure >30 mmHg
● Irreversibel muscle damage - pressure >50 mmHg
● Long surgery time is a distinguishing characteristic associated with this
COMPARTMENT SYNDROME

33. LATERAL
POSITION

34. ● The lateral decubitus position mostly
used for surgery involving the thorax,
retro peritoneal structures, or hip, or
in one lung ventilation method
● The patient rests on the non
operative side and is balanced with
anterior and posterior support
(bedding rolls, inflatable bean bag)
● The patient’s head must be kept in a
neutral position to prevent excessive
lateral rotation of the neck and
stretch injuries to brachial plexus.
LATERAL DECUBITUS POSITION

35. ● Rolled laterally to thte non-operative site
● Lower leg is flexed with padding in
between the legs, and both arms are
supported and padded
● Dependent ear should be checked to
avoid folding and undue pressure
● Eyes should be securely taped closed
before repositioning and frequently
checked for compression
● Kidney rest must be properly placed
under the dependent iliac crest to
prevent compression of the inferior vena
cava.
POSITIONING AND SUPPORTS

36. ● To avoid compression to the dependent
brachial plexus or blood vessels, an axillary
roll is placed between the chest wall and
the bed.
● Pulse should be monitored in the
dependent arm for early detection of the
axillary neurovascular compression

38. ● Patient may be flexed in lateral
position
● To spread the ribs during
thoracotomies
● To improve exposure of the
retroperitoneum for renal surgeries
● The point of flexion should lie under
the iliac crest rather than under the
flank or lower ribs to optimized
ventilation of the dependent lung
FLEXED LATERAL DECUBITUS POSITION

39. PRONE POSITION

40. ● The prone or ventral decubitus position
is primarily used for surgical access to
the posterior fossa of the skull, the
posterior spine, the buttocks,
perirectal area and the lower
extremities
● Patient’s legs should be padded and
flexed slightly at the knee and hip
● Arms may be tucked sidewise neytrally
or on the armboard next to the head
● The head supported facedown or
turned to the side
POSITIONING

41. ● When GA is planned, the patient is first intubated on the stretcher. The tube
is well secured to prevent dislodgement. Wire-reinforced tube is
considered
● With the coordination of the entire operating room staff, the patient is
turned prone into the OR table, keeping the neck in line with the spine during
the move
● Extra padding under the elbow is needed to prevent compromise of the
ulnar nerve

42. CAREFUL PRONE POSITIONING

43. Mayfield (Pin) Head holder
● It supports the head without any
direct pressure on the face
● These pins allow access to the
airway and firmly hold the head in
one position that can be finely
adjusted for optimal neurosurgical
exposure
● Rigid fixation is provided for
cervical spine and posterior
intracranial surgery
● Extreme head positions may
increase the risk of cervical cord
injury
POSITIONING AIDS AND SUPPORTS

44. Horseshoe head rest
● It supports only the forehead
and the malar regions. Allows
excellent access to the airway
and eyes.
● The face is seen from below
● Head height is adjusted to
position the neck in a natural
position
● This head rest is rigid and
therefore potentially
dangerous if the head moves.
POSITIONING AIDS AND SUPPORTS

45. Mirror System
● Bony structures of the head and
face are well supported
● Monitoring of the eyes and airway
is facilitated with a plastic mirror
● The eyes should be taped closed
POSITIONING AIDS AND SUPPORTS

46. ● Arms are abducted less than 90
degrees
● The chest and abdomen are
supported away to the bed to
minimize abdominal pressure to
preserve pulmonary compliance
● Soft head pillows has cutouts
for eyes and nose
● Breasts and genitalia should be
free from torsion
● To promote low abdominal and
thoracic pressure, multiple
paddings and rolls are put in
place
PRONE POSITION WITH WILSON FRAME

48. ● Because the abdominal wall is easily displaced, external pressure on the
abdomen may elevate intra abdominal pressure
● External pressure on the abdomen may push the diaphragm cephalad,
decreasing FRC, pulmonary compliance and increasing peak airway
pressure.
● Careful attention must be paid to the ability of the abdomen to hang free and
to move with respiration
● Abdominal pressure also may impede venous return through compression of
the inferior vena cava.
PRONE CONCERNS

49. AIRWAY
● Accidental extubation
● Obstruction of ET tube
● Facial,airway edema
NECK INJURY
● Excessive lateral torsion or hyper flexion leads to post operative pain,
cervical nerve root or vascular compression
● Accentuation of pre-existing trauma
VISUAL LOSS
COMPLICATIONS

50. ● Used for anal surgeries , pilonidal
excision.
● Places patient prone with head &
feet at a lower level
● The hips are over the center break
of the OR bed between the body
and leg sections
● Chest rolls are placed to raise the
chest
JACK KNIFE POSITION

51. ● Exaggerated Jack knife position
● Used for sigmoidoscopy, lumbar
laminectomy
● Severe hypotension can happen due
to pooling of blood in lower limb
KNEE CHEST POSITION

52. SITTING
POSITION

53. ● The sitting position is preferred in
approaching the posterior cervical
spine and the posterior fossa
● The head may be fixed in pins or taped
in with adequate support
● Arms must be supported to prevent
shoulder traction and stretching of the
brachial plexus
● The knees are slightly flexed for
balance and to reduce stretching
● The legs are kept as high as possible to
promote venous return
● Position produces excellent surgical
exposure, decrease blood in the
operating field, superior access to the
airway, reduces facial swelling.
POSITIONING

54. ● Used for shoulder
surgeries, including
arthroscopic procedures
● The arms must be
supported to prevent
stretching of the brachial
plexus without pressure
on the ulnar area of the
elbow.
● Associated with
neurologic injury, cervical
neurapraxia and
hypotensive bradycardia
BEACH CHAIR POSITION

55. ● Because of the pooling of blood into the lower body, patients under GA
are prone to hypotensive episodes
● Excessive cervical flexion can impede arterial and venous blood flow,
causing hypoperfusion or venous congestion of the brain
● Because of the elevation of the surgical field above the heart, and
inability of the dura venous sinuses to collapse because of their bony
attachment, they risk of venous air embolism is a constant concern
SITTING CONCERNS

56. ● Venous air embolism
● Hypotension
● Airway obstruction
● Macroglossia
● Pneumocephalus
● quadriplegia
COMPLICATIONS

57. THANK YOU!