Surgical Positioning 2010

Surgical Positioning
Positioning
Surgical
Jeffrey Groom PhD, CRNA
Nurse Anesthetist Program
Florida International University
SURGICAL POSITIONING
POSITIONING
SURGICAL
OBJECTIVES
OBJECTIVES
Identify the role and responsibility of the
anesthesia provider in patient positioning.
Describe the complications associated
with improper patient positioning.
Describe the physiological changes that
occur with the various positions.
Identify scenarios involving medicolegal
liability associated with improper patient
positioning.
Surgical table
table
Surgical
Positioning
Surgical
SUPINE
Positioning
Surgical
Trendelenberg Reverse Trendelenberg
Positioning
Surgical
Lateral Tilt
Positioning
Surgical
Lithotomy
Positioning
Surgical
Sitting Beach Chair
Positioning
Surgical
JackKnife - Kneeling
Positioning
Surgical
Positioning
Surgical
Positioning
Surgical
OR Table
Table Attachments
Attachments
OR
Positioning
Surgical
All positioning schemes have 3 goals:
1. Maximum exposure to the surgical area
while maintaining homeostasis and
preventing injury
2. Position must provide the Anesthetist with
adequate access to the patient for airway
management, ventilation, medications, and
monitoring
3. Promote the enhancement of a
satisfactory surgical result
Positioning
Surgical
What happens when the anesthetized patient cant care for themselves?
Positioning
Surgical
When you sleep, you reposition yourself to prevent pressure

ischemia. Under anesthesia, the patient does not reposition
(protect) them self so the responsibility falls to the surgical
team to prevent pressure ischemia & positioning injuries.
Positioning
Surgical
Why is there a risk for injury ?
Positioning and Anesthesia

Blunted or obtunded reflexes prevent
patients from repositioning themselves
for relief of discomfort
Anesthesia may blunt compensatory
sympathetic nervous system reflexes that
would minimize systemic BP changes
with abrupt position changes
Rendering patients unconscious and
relaxed may permit placement in position
they may not have normally tolerated in
an awake state
Patient Injury
Injury and
and
Patient
Positioning
Surgical
Most are nerve injuries due to overstretching and/or
compression.
90% undergo complete recovery.
10% are left with residual weakness or sensory loss.
Many injuries can produce lasting disability.
Many injuries lead to litigation.
General anesthesia removes many of the bodies
natural protective mechanisms.
Recognition of risks and prevention is essential.
How do nerves get

injured? Example
Nerve fiber
Peripheral Nerves from Spinal Cord

only sensory fibers run in the dorsal root
motor fibers (somatic and autonomic) leave the cord via the ventral roots
sympathetic fibers leave the cord via ventral roots from T1 - L2
Peripheral Nerve
Nerve Injury
Injury
Peripheral
Preoperative History and

Physical Assessment
Preexisting patient attributes associated
with increased incidence of perioperative
neuropathies:
extremes of age or body weight,
preexisting neurologic symptoms,
diabetes mellitus,
peripheral vascular disease,
alcohol dependency,
smoking,
and arthritis.
Positioning
Surgical
ASA Closed
Closed Claims
Claims
ASA
1999 - 670 claims for anesthesiarelated nerve injuries
#1 - Ulnar nerve (28%)
#2 - Brachial plexus (20%)
#3 - Common peroneal (13%)
Positioning
Surgical
Ulnar nerve injury

Caused by arms along side patient in pronation
Ulnar nerve compressed at elbow between table
and medial epicondyle.
Prevented by positioning arms in supination.
Hypotension and hypoperfuison increase risk.
Ulnar Nerve
Nerve
Ulnar
Yo sup
sup dude?
dude?
Yo
Positioning
Surgical
Brachial Plexus Injury
Excessive arm abduction or external rotation.
Prevented by avoiding more than 90o abduction.
Secure arm to prevent arm from falling off of table
or arm board.
Brachial Plexus
Plexus
Brachial
Positioning
Surgical
Brachial Plexus
Abduct arms to no more than 90 degrees.
Minimize simultaneous abduction, external arm rotation,
and opposite lateral head rotation.
In prone position, maintain abduction and anterior flexion
of arms above head to no more than 90 degrees.
In lateral position, place chest roll under lateral thorax to
minimize compression of humerus into axilla.
Brachial Plexus
Plexus
Brachial
Positioning
Surgical
Peroneal nerve
Caused by direct pressure on the nerve

with the legs in lithotomy position.
Nerve compressed against neck of fibula.
Prevented by adequate padding of
lithotomy poles.
Positioning
Surgical
Positioning
Surgical
Surgical Positions
Positions and
and
Surgical
Anesthesia Implications
Implications
Anesthesia
Positioning
Surgical
SUPINE
Positioning
Surgical
Supine
Supine
Most frequently used position.
Cervical, thoracic, lumbar vertebrae
should be in a straight, horizontal line.
Minimal effects on circulation.
FRC decreases 25-30% from upright.
Arm boards and arm must be less than
90o abduction angle to the torso.
Positioning
Surgical
Supine (con't)
(con't)
Supine
Arms at greater than 90o angle results in stretch
of the subclavian and axillary vessels resulting
in radial pulse obliteration and arterial
thrombosis.
Injuries have been reported with as little as 60o
abduction.
Palms up- relieves pressure on the ulnar nerve
as it passes through the humeral notch at the
elbow.
Positioning
Surgical
Supine
Supine
Ulnar nerve injury
Hypotension and hypoperfusion
increase risk
Inability to abduct or oppose the 5th
finger
Atrophy of the intrinsic muscles of
the hand (claw hand).
Positioning
Surgical
Supine
Supine
Extreme rotation of the head can cause
occlusion and thrombosis of the vertebral
artery.
Pressure from a mask or head strap can
cause injuries of the supraorbital and
facial nerves.
Relaxation of the paraspinous muscles
and flattening of the normal lumbar
convexity results in tension on the
interlumbar and lumbosacral ligaments
causing a backache.
Positioning
Surgical
Supine
Supine
Positioning
Surgical
Prone
Prone
Prone
Induction completed on stretcher, then patient
logrolled to OR table under command of CRNA
Body logrolled as a unit in a smooth, slow, and
gentle manner.
Neck in alignment with spinal column.
Eyes and ears protected and not depressed.
Chest rolls, or bolsters are placed lengthwise on
both sides of the thorax, extending from the
acromioclavicular joints to iliac crest-adequate
lung expansion and diaphragm excursion.
Positioning
Surgical
Prone
Prone
Protect female breasts & male genitalia.
Pillow under legs & ankles to flex knees
and prevent pressure on toes and plantar
flexion of feet.
Arms at side or extended alongside the
head on arm boards
Documentation: pressure points padded,
free abdominal and chest expansion,
position of the arms, eye care
Positioning
Surgical
Prone
Prone
Cardiac
Pooling of blood in extremities

Compression of abdominal muscles
Decrease preload, c.o., and blood pressure
Increased SVR and PVR
Decreased stroke volume and cardiac index
TEDS or pneumatic sequential compression
stockings to minimize pooling of blood
Positioning
Surgical
Prone
Prone
Respiratory
Decreased lung compliance
Increased work of breathing
Thoracic Outlet Syndrome-secondary to
thoracic nerve compression (agonizing,
debilitating, and unremitting pain postoperatively following overhead arm
placement
ETT dislodgement - Extubation
Positioning
Surgical
Trendelenberg Reverse Trendelenberg
Positioning
Surgical
Trendelenburg
Trendelenburg
Cardiac
Activation of baroreceptors
Decrease in C.O., PVR, HR, and BP
Does not improve C.O. in hypotension & hypovolemia
Respiratory
Decreased FRC, total lung capacity and pulmonary compliance
secondary to shift of abdominal viscera
Increased V/Q mismatching
Atlectasis
Increased likelihood of regurgitation
Use of shoulder braces to prevent cephalad mvmt
Positioning
Surgical
Reverse Trendelenburg
Trendelenburg
Reverse
Cardiac
Decrease in c.o., preload, and arterial
pressure
Baroreflexes increase sympathetic
tone, HR , PVR.
Respiratory
Work of breathing decreased
Increase in FRC
Positioning
Surgical
Lateral Decubitus
Decubitus
Lateral
Positioning
Surgical
Lateral Decubitus
Decubitus
Lateral
Usually positioned with bean bag or
position supports.
Head must be aligned to support the
spinal column and prevent compression of
dependent arm.
Pillows placed between legs and feet
Bottom leg flexed to provide stability and
facilitate venous drainage.
Peroneal nerve susceptible to injury
Positioning
Surgical
Lateral Decubitus
Decubitus
Lateral
Presents anesthetic challenges Compression of vena cava with kidney rest
Dependent lung is underventilated-pressure of
abdominal contents and wt of mediastinum.
Nondependent lung is overventilated because
of increased compliance.
Blood flows to underventilated lung by gravity.
V/Q mismatch may manifest as hypoxemia
Positioning
Surgical
Lateral Decubitus
Decubitus
Lateral
Kidney rest- beneath the bony iliac crest, not under
fleshy waist area
Axillary rolls- placed at scapula near the axillary space
to relieve pressure on the arm and foster adequate chest
excursion.
Dependent shoulder, axilla, and deltoid must be padded.
Lower arm brought forward to prevent pressure on
brachial plexus.
Chest surgery- upper arm flexed at elbow and raised
above head to elevate scaplua and widen intercostal
spaces.
Positioning
Surgical
Lateral Decubitus
Decubitus
Lateral
Cardiac
Output unchanged unless venous return
obstructed (kidney rest).
May see decrease in arterial blood pressure as a
result of decreased vascular resistance (R > L).
Respiratory
Decreased volume and increased perfusion of
dependant lung, V/Q mismatch potential
Positioning
Surgical
Sitting Beach Chair
Positioning
Surgical
Sitting
Sitting
Cardiac
Pooling blood in lower body decreases central blood
volume.
ABP fall despite increase in HR & SVR. (30%)
C.O. decreases 20-40%
Increase in sympathetic /parasympathetic tone
Intrathoracic blood volume decreases as much as 500 ml
Respiratory
Lung volumes are increased.
FRC is increased.
Work of breathing is decreased.
Sitting
Posterior Foss Craniotomy & shoulder
procedures.
Full sitting position is uncommon.
Lounge chair, beach chair.
Facilitates venous drainage.
Venous air embolism risk is potential hazard
Positioning
Surgical
Sitting
Sitting
Complications
Postural hypotension
Air emboli
Potentially lethal
Chances increase with degree of elevation of op site.
Dx: change in heart rate, murmur, decreased in exp CO2,
cardiac dysrythmias, change in heart sounds generated by
a parasternal Dopppler.
TEE most sensitive for detection (0.015 ml/kg/air)
Gasp breath may be first indicator
Decreased Pa02, etCO2, increased etN
Positioning
Surgical
Sitting
Sitting
Complications
Ocular compression
Pneumocephalus
Edema of face, head, and neck due to
prolonged neck flexion resulting in venous
and lymphatic obstruction.
Sciatic nerve injury
Bended knees without flexion of the hips
Foot drop is clinical manifestation
Positioning
Surgical
Lithotomy
Positioning
Surgical
Lithotomy
Lithotomy
Cephalad displacement of the diaphragm.
Principle hazards:
Common peroneal- foot drop
Femoral- decreased or absent knee jerk
Saphenous Obturator-inability to adduct leg & diminished
sensation over medial side of the thigh
Sciatic nerve- weakness of all skeletal muscles below
the knee
Both legs should be elevated & flexed at same time to
avoid stretching of peripheral nerves
Thighs should be no more than 90 o
AANA Scope
Scope and
and Standards
Standards
AANA
for Nurse
Nurse Anesthesia
Anesthesia
for
Practice
Practice
Standard V
V
Standard
Nurse anesthetists should monitor and
assess patient positioning and protective
measures at frequent intervals.
Failure to follow professional standards
and guidelines may result in
positioning injuries and liability.
LIABILITY EXAMPLES
Pommier vs Savoy Memorial Hospital

55 y.o female w/fractured hip
2hr 20 min surgery
Developed peroneal palsy post-op
Protective and monitoring measures were not taken nor documented. No
prior injury present. Conclusion at trial injury would not have occurred
had there not been negligence res ipsa loquitur.
Shahine vs. Louisiana State University

Medical Center,
680 So. 2d 1352 (La. App., 1996)
"#6 table with safety strap in place 2" above knees supine with bean bag underneath patient post
induction & catheter insertion into the left side, with
right side up, per __M.D. & __M.D, - auxiliary roll in
place (1000cc bag IV fluid wrapped in muslin cover)
- held in place per surgeons until bean bag deflated
with suction - pillow placed under right leg with left
leg bent slightly - U drape in place per surgeons pre
prep - left arm extended on padded arm board right arm placed on mayo tray that is padded."
Protective and monitoring measures were taken and documented.
Brachial plexus injury reported postop. No prior injury present.
Conclusion at trial injury was a risk of the procedure however personnel
ASA Practice Advisory Sets a legal standard of care

LINK to Advisory in the Course Outline Page
Upper extremity
extremity positioning
positioning
Upper
Arm abduction should be limited to 90 in supine
patients; patients who are positioned prone may
tolerate arm abduction greater than 90
Arms should be positioned to decrease pressure
on the postcondylar groove of the humerus (ulnar
groove).
When arms are tucked at the side, a neutral
forearm position is recommended. When arms are
abducted on armboards, either supination or a
neutral forearm position is acceptable
Prolonged pressure on the radial nerve in the
spiral groove of the humerus should be avoided
Extension of the elbow beyond a comfortable
range may stretch the median nerve
Lower extremity positioning

Lithotomy positions that stretch the hamstring
muscle group beyond a comfortable range may
stretch the sciatic nerve
Prolonged pressure on the peroneal nerve at the
fibular head should be avoided
Neither extension nor flexion of the hip within
normal range of motion increases the risk of
femoral neuropathy
Protective padding
Padded armboards may decrease the risk of upper
extremity neuropathy
The use of chest rolls in laterally positioned
patients may decrease the risk of upper extremity
neuropathies
Padding at the elbow and at the fibular head may
decrease the risk of upper and lower extremity
neuropathies, respectively
Equipment
Properly functioning automated blood pressure
cuffs on the upper arms do not affect the risk of
upper extremity neuropathies
Shoulder braces in steep head-down positions may
increase the risk of brachial plexus neuropathies
Postoperative assessment
A simple postoperative assessment of
extremity nerve function may lead to early
recognition of peripheral neuropathies
Documentation
Charting specific positioning actions during the
care of patients may result in improvements of
care by (1) helping practitioners focus attention
on relevant aspects of patient positioning; (2)
providing information that continuous
improvement processes can use to lead to
refinements in patient care; and (3) provide
medicolegal defense
Positioning
Surgical
Positioning Checklist
Checklist
Positioning
1. Head, neck and cervical spine supported in a
straight line.
2. Scalp, head, and face protected from tight
anesthesia mask/straps.
3. Ears protected from traumatic pressure/objects.
4. Chest and torso kept in physiological position for
adequate full, bilateral respiratory exchange and
expansion.
5. Breasts & genitalia protected from excessive
pressure.
6. Arms in physiological position and supported.

- not to exceed 90 degree extension at shoulder
- in flexion not hyperextension
- upper arm not hanging over edge of table
or rubbing
on metal part of table
- elbow area protected from ulnar pressure
- hands free of pressure and compression
- fingers in slight flexion or neutral extension
- wrist restraints loose or padded
- palms up on armboard
- palms towards body when arms at side
7. Genitals free of trauma, pressure, or rubbing.
8. Back in physiological position, spine in straight line
- slight sacral curvature
- soft small positioning devices under sacral area and
knees to relieve
pressure, pain, or stretching.
9. Thighs/legs in straight line of flexed position; no pressure
to iliac crests, greater trochanters, area bt back & knees,
peroneal nerve on lateral aspects of knees, or to patellas.
10. Heels/ankles/toes free of pressure or rubbing trauma.
11. Safety belt placed snugly over patient w/blanket or towel
between strap and patients body to prevent maceration.
12. Other straps or positioning devices placed only over
padded body parts.
Positioning
Surgical
During clinical this semester spend time
after cases learning the operation of the OR
table and proper positioning. Practice on
each other to appreciate positioning from
patients perspective.

Surgical Positioning 2010

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Surgical Positioning 2010

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Surgical Positioning

When you sleep, you reposition yourself to prevent pressure

Positioning and Anesthesia

How do nerves get

Peripheral Nerves from Spinal Cord

Preoperative History and

Ulnar nerve injury

Caused by direct pressure on the nerve

Pooling of blood in extremities

Use of shoulder braces to prevent cephalad mvmt

Pommier vs Savoy Memorial Hospital

Shahine vs. Louisiana State University

ASA Practice Advisory Sets a legal standard of care

Lower extremity positioning

6. Arms in physiological position and supported.

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