Patient Positioning in the Operating Room, by Dr. Beverly Chang
For the purpose of this demonstration, the physician in this video is not wearing gloves.
In practice, we encourage the use of gloves, and adherence to personal protective equipment
standards Hello my name is Beverly Chang and I am here
today to introduce the topic of Patient Positioning in the Operating Room.
Introduction.
Positioning in the operating room is a very important topic that has large implications
towards patient’s post-op wellbeing.
The reason why positioning is important is the potential to avoid nerve injuries as well
as soft tissue injuries during the intra-operative period.
Most common upper extremity nerve injuries include the ulnar nerve and the most common
lower extremity injury is the peroneal nerve.
And while most cases of post-op nerve injury usually resolve in 6 to 12 weeks, patients
that do suffer from these complications have significant distress in the post-operative
period related to these complications.
The most commonly proposed etiology of nerve injury is mainly contributed to external pressure
on the nerve that has been proposed to compromise perfusion, disrupt cellular integrity causing
edema, ischemia, necrosis, which manifests as nerve injury and nerve palsy in the post-operative
period.
Data have suggested that some peripheral nerve injury is not entirely preventable, however,
with positioning we can minimize the chances of these occurrences in the intra-operative
as well as post-operative period.
Incidents & Risk Factors.
The incidence of peripheral nerve injuries in pediatrics is actually reported to be much
lower than that among adults so it has been reported to be around 1% in pediatrics versus
16% in adults.
Upward extremity neuropathies are more common than lower extremity neuropathies.
Certain risk factors have been attributed to contribute to possible nerve injuries during
the intra-operative period and these include body habitus, mainly obese patients, pre-existing
neurological symptoms, diabetes, peripheral vascular disease, alcohol dependence, arthritis,
as well as there is an association between ulnar neuropathy as well as the male gender.
For positioning specifically in the pediatric position, the main things to watch out for
are large facemasks that will compress the eyes during mask ventilation.
For prone positioning watch out for the endotracheal tube, make sure there are no kinks as well
as preform constant eye checks to make sure there’s no compression on the eyes.
Extremities should always be padded; paper cups can also be used to pad the extremities
in tiny infants that, where padding may not be as appropriate and this will be demonstrated
later on in the video.
Also make sure that all wires and lines that are in contact with the child’s body should
be padded so there’s no contact between the wires and lines and the patient’s body.
Extremity Positioning.
Some important points for positioning upper extremities and this is-- applies to both
pediatrics as well as for adult patients.
Limit upper arm abduction to less than 90 degrees when supine.
Prone positioning also affects shoulder and brachial plexus mobility different than in
the supine position so when you are in the prone position you may be able to tolerate
an abduction of their arms greater than 90 degrees if it cannot be prevented.
Upper extremities should be positioned to decrease the pressure on the post-condylar
groove of the humerus, this is to prevent any type of ulnar compression at that point.
And patients should be able to tolerate both supination or neutral forearm position, but
the prolonged prone positioning can compress the ulnar nerve in the cubital tunnel, as
well as flexion of the elbow can increase a risk of ulnar neuropathy as well, but there
really is no consensus as to how much flexion at the elbow is desirable.
Prolonged pressure on the radial nerve and the spiral groove of the humerus should also
be avoided.
Periodic assessments of maintenance of the desired position should be documented every
thirty minutes.
Some important points for the positioning of lower extremities.
Because the sciatic nerve and its branches do cross both the hip as well as the knee
joints, extension and flexion in these joints should be considered when you determine the
degree of hip flexion during positioning.
Neither extension or flexion of the hip has been shown to increase the risk of femoral
neuropathy and prolonged pressure on the peroneal nerve at the fibular head should be avoided
to prevent peroneal nerve injury.
Adult Positioning Demonstration.
Adult supine position.
Make sure to apply eye tape to the eyes to protect them from possible abrasion as well
as external pressure.
Make sure all wires as well as lines are padded and pay special attention to pressure points
and make sure those areas are cushioned or padded as well.
For arms that are out and not tucked, make sure to check periodically that the arms are
still on the arm boards.
There have been instances where during the procedures arms have fallen off the arm boards
and due to the fact that they are under the drapes that these have not been noticed until
after the procedure and this can cause significant nerve as well as soft tissue injuries in the
post-operative period.
One thing that can be done to make sure that this doesn’t happen is to apply arm straps
prior to the procedure itself to make sure that the arm stays in proper position during
the entire procedure.
Adult prone position.
For adults in the prone position make sure that the eyes as well as the endotracheal
tube is positioned properly within the prone face pillow, make sure that there is no external
compression on the eyes.
In certain instances the head can be placed in a lateral position rather than using a
prone position pillow.
Arms should be abducted less than 90 degrees as much as possible.
Wires should be ensured that they’re not crossing the neck causing any sort of pressure
or any sort of strangulation issues in that area.
Pillows should be placed below the legs to cushion these pressure points and make sure
that not parts of the extremities are free floating.
Adult’s lithotomy position.
To place adults in the lithotomy position, two members of the anesthesia or the OR team
should be used.
Both legs should be lifted simultaneously as well as abducted simultaneously, the same
goes when the legs are lifted back down into the regular supine position as well, two members
should be used, the legs should be abducted at the same time and placed down at the same
time.
Adults lateral position.
An axillary role should be placed to prevent nerve injury in the axilla, make sure that
there is no direct compression of the axilla itself in placing the role.
Ensure that there is at least two finger breadths space between the role as well as the axilla.
In the lateral position place pillows between the legs to cushion these pressure points
as well as pad any other areas that may cause any external compression.
Once again make sure all pressure points are padded and also make sure that the spine as
well as the head is supported in a neutral position.
Pediatric Positioning Demonstration.
Pediatric supine position.
Make sure to pad all wires and lines to ensure that no parts of any wires or lines are in
direct contact with the patient’s body.
Make sure that all the extremities are padded, especially in pressure points.
For infants, paper cups can be cut in half and used to cover the extremities and these
are appropriate for infants where larger padding as well as cushioning may not be as appropriate.
Pediatric prone position.
For children in the prone position, the head can be placed in a lateral position instead
of being placed in a prone pillow.
Older children can use the prone position pillow similar to adults.
Make sure to check the eyes as well as the endotracheal tube for proper positioning,
ensure that there is no external compression of the eyes and proper documentation of eye
positioning should be performed every 15 minutes during the intra-operative period.
Make sure to pad all pressure points and make sure to pad all wires and lines so that they
are in no direct contact with the patient’s body.
Make sure that the arms are in less than 90 degrees abduction or to the patient’s side
and just make sure that no parts of the extremities are free floating.
Pediatric lateral position.
An axillary role should be placed right below the axilla, however make sure that there is
two finger breadths between the role as well as the axilla to prevent any axillary nerve
injury.
Make sure that the spine as well as the head is in a neutral position.
Make sure to pad all pressure points.
Thank you very much for your attention today.