Positions

Related
Injuries
Dr/ Nour El-Hoda Nasr. Professor of Anesthesia, ICU and
pain management.
Prepared by: Dr/ Fatma Alzahraa Roshdy Elkemary
Lecturer of Anesthesia, ICU & pain management
Agenda

• Goals of Patient Positioning.

• Respiratory-Vascular-Musculoskeletal-Nervous System,
Considerations.
• Positioning Injuries
1. Extrinsic Factors
2. Patient Factors
• Preoperative Assessment.
• Types of positions.
• How to prevent injury?
• Take home message.
• Quiz..
For each perioperative patient:

1 2 3
1-Assess the patient’s 2-Use a risk assessment 3-Communicate the
risks for tool to identify risks for patient’s risks for injury
• Skin breakdown pressure injury and pressure injury to
• Pressure injury development (Braden all perioperative team
• Injury due to patient Scales) (adult and members.
positioning pediatric).
 During • Physiologic changes
General/Regional • Patients cannot feel pain or pressure.
anesthesia there • Patients are unable to move independently.
are • Patients lack protective reflexes.
• Patients lack normal perception.
Respiratory Considerations

A surgical position can compromise respiration.

The abdominal viscera can shift upward toward the diaphragm and affect
ventilatory force and may decrease tidal volume (ie, supine, prone, lateral).
Patient conditions (eg, obesity, pregnancy, pulmonary disease) and the patient’s
position in surgery can affect the respiratory system.
Vascular
Considerations
• Peripheral vessels dilate during
general anesthesia, reducing blood
pressure.
• Blood pools to lowest body part or
dependent areas.
• All surgical patients are at risk for
venous thromboembolism.
• Acute compartmental syndrome can
occur when an extremity is not
positioned correctly, or there is
excessive constriction to the extremity
Musculoskeletal
Considerations
Maintain the patient in a neutral alignment to avoid
over-stretching of muscles, tendons, ligaments.
• Determine if the patient has limitations in range of
motion.
• Support the extremities during position changes.
• Avoid excessive joint extension.
Nervous System
Considerations
• Anesthetics depress the nervous system and normal
compensatory mechanisms are compromised.

• Collateral damage to surrounding tissue can impact

nourishment to nerves.

• Nerves can be injured by compression, ischemia,

and stretching
Brachial Plexus Injury

• How an injury may occur

– Arm boards are extended beyond 90 degrees
– Arm boards are higher or lower than the OR bed
– Lateral rotation of the patient’s head
– Team members’ lean against the shoulder or arm
– Use of shoulder braces
Common Peroneal Nerve
• How an injury may occur
– Direct compression
– Thin patients are at risk
– Hyperextension of knees
– Pressure behind the knee
– Graduated compression stockings are too tight
– Foot drop, lower extremity paresthesia
Positioning Injuries
Extrinsic Factors
Positioning Injuries
Extrinsic Factors
 High body mass index (BMI)

Low BMI
Positioning
Poor nutritional status
Injuries –
Patient Advanced age
Factors History of smoking

History of previous skin breakdown

Preoperative Assessment

• Age/Height/Weight/BMI
• Nutritional status
• Blood pressure
• Skin integrity
• Range of motion/Physical limitations
• Internal/External devices
• Preexisting conditions
• Medical history
• Diagnostic studies
• Psychological/Cultural
considerations
Supine Position
1-Supine Position
Because most surgical procedures involve
patients in the supine position, a clear
understanding of the pathophysiologic effects
of this position is necessary for the
perioperative team.
A significant portion of our life is spent in the
supine position, and this position is not
usually considered to pose significant
physiologic stress on the body.
However, patients with morbid obesity,
mediastinal masses, poor cardiac functional
status, and term parturient prone to
aortocaval compression do not easily tolerate
Pathophysiology of
the Supine Position

• CVS:
Moving from erect posture to the
supine position increases central
blood volume considerably. As a
result of this increased blood
volume, compensatory stretch
and baroreceptors in the central
circulation initiate reflex
responses that usually maintain
blood pressure within narrow
limits.
• Resp:
↓FEC
↓ ventilation–perfusion
mismatching
↓TV
↑pulmonary compliance
Airway obstruction
Other complications
of supine position

• Increased risk of regurgitation of

gastric contents.
• The eye is at particular risk of direct
or indirect trauma and it should be
remembered that corneal drying can
occur in as little as 10 min if the eye is
left exposed.
• Both supraorbital and facial nerves are
at risk of crush injuries from
facemasks and endotracheal tube ties,
respectively.
• The classic supine position leads to
loss of the natural lumbar lordosis
and this is associated with
postoperative low back pain.
Maintenance of the lordosis with an
inflatable wedge or another suitable
device should be considered in all
patients.
• The occiput ,sacrum and heel are at
risk of developing pressure sores
and these areas should always be
well padded. If heel pads are used,
it is wise to ensure that the knee
still maintains some degree of
flexion otherwise a hyperextension
injury may result.
2-Trendelenburg
(head down) position
• The Trendelenburg position involves
placing the patient head down and
elevating the feet .It is named after
German surgeon Friedrich
Trendelenburg, who created the
position to improve surgical exposure
of the pelvic organs during surgery.
• In World War 1 , Walter Cannon, the
famous American physiologist,
popularized the use of Trendelenburg
position as a treatment for shock. It
was promoted as a way to increase
venous return to the heart, increase
cardiac output and improve organ
perfusion
Physiologica
l changes:
• The head-down position ↑
central venous, intracranial,
and intraocular pressures.
• Prolonged head-down position
also can lead to swelling of the
face, conjunctiva, larynx, and
tongue with an increased
potential for postoperative
upper airway obstruction.
The cephalic movement of abdominal viscera against the
diaphragm also ↓FRC and pulmonary compliance.

In spontaneously ventilating patients, the work of breathing

increases.

In mechanically ventilated patients, airway pressures must be

higher to ensure adequate ventilation.

The stomach also lies at a level higher than the glottis.

Endotracheal intubation is often preferred to protect the airway
from pulmonary aspiration related to reflux and to reduce
atelectasis
Prolonged head down can lead to post
operative vision loss…..?
3-Reversed Trendelenburg
(head -up tilt) position
• head-up posture results in a ↓ in
cardiac index and filling pressure,
compensated for by an ↑ in
systemic vascular tone .Systemic
vascular resistance ↑ slightly,
whereas CVP and mean pulmonary
artery pressure ↓ mildly .
• Hypotension may result from
positioning in reverse
Trendelenburg and the anesthetist
should account for the hydrostatic
gradient between the blood
pressure cuff and the brain, to
prevent cerebral hypoperfusion.
How to prevent injury ?
 4-Lithotomy
Position
• This position is most often used for
genitourinary, gynecologic, and
colorectal procedures. The standard
lithotomy position is achieved when the
• patient's legs are abducted from the
midline and the hips and knees are
flexed so that the lower legs are parallel
to the floor. It is prudent that both
• lower extremities be raised and lowered
simultaneously while using this position
to avoid rotational stress on the lumbar
spine.
• It is important to remember that the
leg elevation redistributes pooled
lower limb blood and this may lead to
volume overload in susceptible
individuals.

• There is almost always some cephalad

movement of the endotracheal tube
upon assuming the lithotomy from the
supine position.
• Unanticipated stimulation of the carina
with bronchospasm or endobronchial
intubation may result.
Different methods of
leg support during
lithotomy positions

• To minimize the risk of injury to

the patient, it is important to
understand the advantages and
limitations of the various
supporting devices (candy cane,
knee crutch, calf support,
cushioned dorsal boot,
adjustable knee, and foot
support) for the lower
extremities.
Physiological changes during lithotomy position

•Pulmonary and cardiovascular changes in this position

are generally similar to, but more extreme than, those
associated with the supine position. Diaphragmatic
movement can be limited severely by the weight of the
abdominal viscera; this further↓ FRC and increases
atelectasis.
• Ventilation-perfusion mismatch, ↑ ICP, ↑ IOPand passive
regurgitation are potential complications; the severity
and likelihood of these increases with amount of tilt.

• The leg elevation redistributes pooled lower limb blood

and this may lead to volume overload in susceptible
individuals
 • Under general anesthesia, with the
assumption of the lithotomy position the
Physiological tidal volume decreases by 3%. With a 10
degrees head down tilt, tidal volume
changes during decreases another 14%.
• Although conscious patients can usually
lithotomy position compensate and tolerate this change in
tidal volume because of improved resting
position of the diaphragm, anesthetized
patients breathing spontaneously may
develop basilar atelectasis and hypoxia.
Patients with obesity, hiatal hernia, and
gastroesophageal reflux disease may
have decreased lower esophageal
sphincter tone and barrier pressure,
increasing the risk for regurgitation and
aspiration of gastric contents in the
lithotomy position.
Complications of lithotomy
position

• The lithotomy position is also associated with the uncommon complication of

compartment syndrome of the lower leg. Decreased arterial perfusion to the legs, due to
both elevation of the limbs and obstruction of venous drainage ,contribute to a rise in
compartment pressure.
• Although it has been reported in shorter cases, patients are at greatest risk of
compartment syndrome during prolonged procedures of more than four hours. Other
factors associated with compartment syndrome include hypotension, hypovolaemia and
the degree of leg elevation. Patients may complain of pain that is out of proportion to
clinical findings. Classical signs such as paraesthesia and pain on passive toe extension
typically occur later in the process.
• Obstruction to venous drainage also predisposes patients to development of venous
thrombosis. Therefore, prophylaxis with compression stockings or sequential
compression devices should be considered in all cases.
• Special care must be taken with the patient hands, which when placed by the patient’s
side may be injured when the table position is altered. Hands must be adequately
protected and then monitored with any movement of the table in order to avoid crush
injuries.
5-Lateral Decubitus
Position
• Access to the airway when a patient is positioned laterally
is suboptimal. Therefore the airway device must be
properly secured to prevent inadvertent dislodgment
during the procedure.
• Ventilation in the anaesthetised patient is altered in the
lateral position. Perfusion is greatest in the dependent
lung and ventilation is greatest in the non-dependent lung,
which leads to V/Q mismatch This can lead to hypoxia in
susceptible patients. This differs from the awake
spontaneously breathing patient where both perfusion
and ventilation are greatest in the dependent lung.
• Although haemodynamics are unlikely to be affected,
consider the placement of the blood pressure cuff.
Placement on the lower arm may lead to compression of
the cuff and therefore inaccurate readings.
Complications
• The radial nerve and the common peroneal nerve are particularly susceptible to
positioning injury in the lateral position.
• The radial nerve of the superior arm may be injured when the arm is suspended, if the
shoulder is abducted to greater than 90 degrees.
• To prevent this injury, abduction of the shoulder should be limited to less than 90
degrees. The forearm can be supported with specially designed rests, or the upper arm
can hug a pillow.
• The common peroneal nerve may be compressed against a hard table where it passes
superficially against the fibular head and should be appropriately padded. Additionally,
the saphenous nerve needs to be protected with padding placed between the legs.
• The head must be supported so as to maintain the neck in a neutral position and prevent
stretching of the brachial plexus.
• An axillary roll can be used to support the thorax and prevent compression of the lower
arm. It must be placed caudad to the axilla on the rib cage. Placing this roll in the axilla
can lead to pressure on the brachial plexus and subsequent neuropathy.
• Ensure the ear has not folded during positioning and all pressure areas have been
appropriately padded. After positioning laterally, confirm the eyes are taped shut and
that pressure is not being applied to the globe.
6-SITTING / BEACH-CHAIR
• The sitting or beach-chair position is commonly used in
shoulder surgery and in some intracranial surgery,
particularly of the posterior fossa.
• Access to the airway may be limited by surgical draping
and the surgical field will be close to the airway, so it is
essential to ensure the endotracheal tube is well secured.
• Hypotension may result after sitting the patient up. In an
awake patient, the sympathetic nervous system will be
activated by the baroreceptors upon sitting up and there
will a rise in systemic vascular resistance which maintains
blood pressure.
• In the anaesthetised patient, these reflexes are less
active and significant hypotension can result. It is
important to sit patients up slowly and treat hypotension
with volume resuscitation and vasopressors.
Placement of the blood pressure cuff is of paramount
importance. If non-invasive blood pressure monitoring is
used, the cuff must be placed on the non-operative arm
and not on the leg. The blood pressure to the brain will
be 15-20mmHg lower than what is being detected in the
arm and this should be accounted for.

If invasive blood pressure monitoring is used, it is

advisable to place the transducer at the level of the
tragus to allow for this. Guidelines suggest that mean
arterial pressure should be maintained >70mmHg, or
within 25% of baseline blood pressure after the
hydrostatic gradient has been taken into account.
 1-Cerebral ischaemia due to result from hypotension,leading to inadequate cerebral
perfusion.

2- hypotension should be avoided. If hypotension is unable to be effectively treated,

lay the patient supine.

3- Hypocapnia should also be avoided in ventilated patients, as it may lead to cerebral

Complication vasoconstriction and may impair cerebral perfusion

s 4-Venous air embolism

5 paradoxical air embolism in patients with a patent foramen ovale, or other shunts
from the right to left heart, are susceptible to. If air enters the systemic circulation,
even small amounts can lead to ischaemia and have devastating consequences.

NB: Care should be taken to apply padding to all pressure points, particularly the
heels, ankles and elbows. Ensure arms are supported. Avoid excessive flexion of the
neck as cases of quadriplegia have been reported
Venous air embolism
• Mech:
Negative venous pressure may occur at the surgical site when in the sitting position;
this is particularly so intracranially, as the veins are held open by dura and bone. The
effects of the air embolism depend on its size.
• A small embolism (<10mL) will only be detected by transoesophageal
echocardiography, but the anaesthetist should alert the surgeon to look for the
source.
• A moderate-size air embolism (10-50mL) will be noticed clinically with a decrease
in end-tidal carbon dioxide and a rise in heart rate and blood pressure from a
sympathetic response. If being monitored, a rise in pulmonary artery pressure will
be noted.
• A large embolus (>50mL) can be catastrophic, leading to tachycardia, arrhythmias,
hypotension, right ventricular failure and cardiac arrest. A decrease in oxygen
saturation may not be seen if a high inspired oxygen concentration is being used.
TTT
Alert the surgeon who Manage hypotension
will apply fluid to the with fluid resuscitation
Increase the oxygen
surgical field and and vasopressors, and
concentration to 100%,
attempt to find the treat any arrhythmias. If
source. possible,

Attempting to aspirate
Place the patient in the air via a central venous
left lateral catheter will not be
Trendelenburg position. successful in many cases
but can be attempted.
7-Prone position
Prone position
• This position is utilised for several different types of surgery including intracranial and
spinal surgery and Achilles tendon repair.
• The airway is very difficult to access after a patient has been positioned prone and
therefore care and attention must be spent securing it. Tapes or ties are appropriate, but
consider the pressure that a tie may exert on the face when the patient is turned.
• Take care when turning the patient, as the tube is vulnerable to movement and tube
position should be rechecked clinically after turning.
Physiologi • Ventilation may actually improve
with prone positioning due to an
cal increase in FRC relative to the
supine position.

changes: • However, if pressure is exerted on

the abdomen this effect may be
reduced due to raised intra-
abdominal pressure and a
decrease in compliance. Patients
should be supported on bony
areas with supports placed across
the chest (just below the clavicle)
and the pelvis, allowing the
abdomen to remain free of
pressure.
• Prone positioning causes a
decrease in cardiac output.
Contributing to this is a reduction
in venous return, effects on
arterial filling and decreased left
ventricular compliance due to
higher intra-thoracic pressures.
Precaution • Access to the patient is limited once the
patient is positioned. Consider this when
s during securing intravenous access and avoid
intravenous cannulae in the antecubital
positionin fossa, as these are likely to become kinked
while prone.
g • Disconnect nonessential lines when
turning the patient to minimise the risk of
inadvertent removal.
• Cardiopulmonary resuscitation is
problematic in the prone position and
positioning of defibrillator pads is very
difficult. In high risk cases, consider
application prior to turning the patient
prone
• Arms should be positioned either
by the patient’s side or with the
hands above the head. If the
hands are positioned above the
head, the shoulder must be
abducted less than 90 degrees
without posterior movement at
the shoulder, the elbows should
be flexed and the hands should be
pronated to minimize risk of injury
to the brachial plexus.
• The head and neck should be maintained
in a neutral position throughout. There is
potential for both spinal nerve injury and
for carotid or vertebral artery blood flow
to be reduced with excessive movement.
• There are many potential pressure areas in
the prone patient. Special head rings
minimise pressure areas on the face, but it
is important to ensure there is no pressure
on the eyes or nose. Pressure areas may
develop on the breasts, genitalia and over
bony prominences.
Take home message

• A range of patient positions are required to optimize surgical access, however each
position has consequences and potential risks that need to be considered. In all
positions, particular care needs to be taken to ensure pressure areas are padded and
limbs are positioned anatomically to minimize the risk of nerve injury.
True or False:

• 1. Lithotomy position may be associated with:

• a. Compartment syndrome
• b. Peripheral neuropathy
• c. Deep vein thrombosis (DVT)
• d. Hand Injury
• 2. Venous air embolism (VAE) is a potential complication of surgery in the sitting position. Regarding
VAE:
• a. All VAE can be detected clinically by a decrease in end tidal carbon dioxide
• b. A decrease in oxygen saturation will not always be seen, even with larger emboli
• c. VAE can lead to arrhythmias, right ventricular failure and cardiac arrest
• d. The surgeon has no role in the management of VAE
• 3. Regarding complications of patient positioning during anaesthesia:
• a. Eye injury only occurs when patients are positioned prone
• b. Supine is the only position not associated with injury from pressure areas
• c. Cerebral ischaemia can occur in the sitting position
• d. Steep Trendelenburg positioning may be associated with development of airway oedema