PATIENT POSITIONING

IN ANESTHESIA

Presented by: Dr. Khaled Alharazin

Supervisor: Dr. Hesham Alzenati
OUTLINES

 Introduction.
 Planning, equipment and personnel.
 Risks due to positioning.
 Patient position in anesthesia.
 Recommendations.
1. INTRODUCTION

 Patients are often required to assume positions for surgery which would be
intolerable without anaesthesia.
 Patient positioning has implications upon the patient’s physiological responses
as well as potentially causing injury to the patient.
 Staffing and equipment provision levels must be adequate to cope with the
complexity predicted in positioning.
 Some specific positions are linked to particular mechanisms of injury.
 All team members involved in moving the patient must be clear on the
actions required to achieve the new position.
2. PLANNING, EQUIPMENT & PERSONNEL

 All equipment should be checked prior to use.

 The operating table should be checked to ensure that it suits positioning
requirements.
 In the case of obese patients, the maximum weight capacity of the table should
be considered.
 There are operating tables that support patients up to 454 kg.
 A team leader (usually the anaesthetist controlling the airway) should be identified
and each team member should have a clearly allocated role
 Accessory equipment used for safe and optimal position may include:

• Head-ring or head support system

• Arm supports and boards
• Gelpads’ and ‘sandbags’
• Leg supports or stirrups
• Fixed supports that attach to operating table (e.g. hip post)
• Foam mattress and foam facial support devices (e.g. Prone View)
• Table straps
• Vacuum positioning systems
• Ample soft material for padding.
 3. RISKS DUE TO POSITIONING

 3.1 Physiologic Vs Mechanical

Patient factors Physical factors Physiologic factors

Gender (M > F) compression Hypoxia

Age stretch Hypotension

Obesity, DM Sharp trauma Dehydration

Neuropathy Shear Hypothermia

Steroids Temperature Electrolyte disturbance

Vascular disease Burns

 3.2 Perioperative peripheral nerve damage:

• In an analysis of the (ASA) Closed Claim Database, nerve injury accounted for 12 %
of malpractice injury claims between 1990 and 2013 for patients who had general
anesthesia.

• Ulnar nerve, brachial plexus and lumbosacral nerve roots are associated with the
majority of malpractice claims.

• Etiology includes: nerve compression, stretch and ischemia.

• Symptoms are more commonly present between 1 and 7 days after surgery.

• Measures to decrease incidence: careful positioning, well protection to vulnerable

areas and avoidance of hypothermia, hypotension and dehydration
 3.3 Skin tissue damage:

• Pressure induced injury may occur over bony prominences.

• Reduction in tissue perfusion can lead to ischemia and necrosis.
• Prevention: Careful positioning, padding and regular assessment.
 3.4 Eye injury:

• Incidence of corneal abrasion under anesthesia has been estimated as

0.034%-0.17%
• It may occur as a result of injury to cornea from drapes, facemasks, hard
materials or chemicals such as cleansing agents.
• Corneal abrasion occurs in the unclosed and non blinking eye due to
reduction of tear flow and loss of blink reflex.
• Tapping the eye closed is more protective than applying ointment.
4.1 SUPINE POSITION

 FRC is reduced.
 Greater tendency for hypoxemia from VQ mismatch.
 In pregnancy, reduced venous return due to compression of the IVC by the gravid
uterus resulting in hypotension.
 Head pillow or soft padding should be used to prevent direct pressure on the
occiput.
 Alopecia has been reported after prolonged contact with the occiput against a theatre
table.
4.1 SUPINE POSITION

 Pressure on the heels and calf should be reduced by a soft pillow placed
behind the knees.
 A knee pillow lessens flattening of the lumbar lordosis on a firm operating table
and prevents overextension at the knee.
 The patient’s arms can be placed at the side or across the chest.
 Ulnar nerve damage is the most common perioperative nerve injury with an
incidence of up to 1 in 350 surgical patients reported.
 Avoid direct pressure on the ulnar nerve particularly at the condylar groove at
the elbow
4.1 SUPINE POSITION

 Forearm is kept in neutral position or slightly supinated.

 Excessive flexion at the elbow results in stretching of the ulnar nerve and should be
avoided.
 The degree of abduction at the shoulder should be kept at less than 90 degrees to
prevent stretching the brachial plexus.
 Patient's head should be in neutral position or turned toward the abducted arm.

 Radial nerve is uncommon but can occur by direct pressure over the posterior
upper arm.
 Beware of tight ties, straps, tourniquets or cables causing direct pressure to skin or causing
compression to nerves.
4.2 LATERAL POSITION - PHYSIOLOGIC EFFECT

 Cardiovascular:
• Blood may pool in the dependent lower extremities, causing reduced venous return
to the central circulation and hypotension.
• Inferior venous cava can be partially or completely obstructed by marked flexion at the
hips.

 Pulmonary effects:
• Perfusion of the dependent lung usually increases, while ventilation of the
dependent lung decreases.
• At the same time, ventilation increases and perfusion decreases in the nondependent
lung.
• Result is VQ mismatch
4.2 LATERAL POSITION - CONSIDERATIONS

 The lateral position may be used for surgery to the hip, buttocks, back,
abdomen and chest.
 It is also used occasionally for head and neck procedures as the ‘park- bench’
position
4.2 LATERAL POSITION - CONSIDERATIONS

 Head should be kept neutral whenever possible, to prevent stretching of the brachial
plexus.
 The arms are generally positioned forward and flexed.
 A chest roll placed below the dependent arm and under the upper thorax may be used to
prevent pressure on the neurovascular structures in the axilla.
 Place cannulas and blood pressure cuffs on the arm that will be uppermost whenever
possible.
 Pressure points should be checked and padded.
 A pillow can be placed between the knees in order to prevent injury to the common
peroneal and saphenous nerves.
 The patient should be stabilized in the lateral position with fixed supports
4.3 LITHOTOMY - PHYSIOLOGIC EFFECTS

 The patient is supine and the hips are flexed and slightly abducted to expose the
perineal region.
 The lithotomy position is increasingly used for laparoscopic
abdominal surgery as well as for pelvic surgery.
 Minor and transient increase in venous return.
 Reduced FRC with increased to hypoxemia and hypoventilation.
 Raised intraabdominal pressure.
 Increased risk of regurgitation.
4.3 LITHOTOMY – NERVE INJURY

 Incidence has been estimated to be between 0.028% and 1.5%

 The sciatic, femoral, lateral femoral cutaneous or obturator nerves may all be
injured by excessive hip flexion.
 The most common lower limb nerve injury is to the common peroneal
nerve as it rounds the top of the fibula laterally.
 Avoid extreme knee flexion and long surgical periods.
 The saphenous nerve may be compressed by leg supports as it passes
superficially over the medial condyle of the tibia.
4.3 LITHOTOMY – NERVE INJURY

 Lateral femoral cutaneous and obturator nerves injury occurs due to hip flexion
beyond 90 degrees causing stretching of the inguinal ligaments.
 Sciatic nerve can be stretched at the level of the hip or knee or may be compressed
distally in the popliteal fossa.
4.3 LITHOTOMY – CONSIDERATIONS

 The patient's legs should be simultaneously placed in leg supports or stirrups by two
attendants.
 Back pain: the lithotomy position may aggravate radicular pain in patients with
a preexisting herniated lumbar disk.
 Compartment syndrome: rare but risk factors include: long procedure time, excessive
dorsiflexion of the ankle and tight leg straps.
 Pathophysiology is complex including impaired tissue perfusion and muscle
oxygenation.
4.4 TRENDELENBURG

 Is a supine position with the operating table head tilted down.

 Improves exposure of pelvic organs during abdominal and laparoscopic surgery

and may be used briefly to facilitate central line placement.

 If the arms are abducted on arm boards, they should be secured with padding,
straps, or taping to avoid movement during change in position.

 Brachial plexus injury can occur when shoulder supports (eg, shoulder braces or
bean bags) are placed at the base of the neck.
4.4 TRENDELENBURG - PHYSIOLOGIC EFFECTS

 Cardiovascular:
Increased VR, with a <45 degree of tilting, central venous pressure, mean pulmonary
artery pressure and pulmonary capillary wedge pressure increase by two to three folds
without significant change in cardiac output or heart rate.

 Pulmonary:
• Cephalad movement of diaphragm causes reduction in FRC, small airway collapse
and respiratory compromise.
• Raised intracranial and intraocular pressures.
• Facial, tongue and airway edema may occur specially with excessive iv fluid
administration.
• Increased risk of aspiration and regurgitation.
4.5 REVERSE TRENDELENBURG

 Head up position results in the opposite physiological effects to those induced in

Trendelenburg.
 It is often employed at induction and emergence of anaesthesia particularly in
obese patients.
 The risk of regurgitation of gastric contents is also reduced.
 Hypotension due to venous pooling in the legs is highly likely in steep reverse
Trendelenburg
4.6 SITTING OR DECK-CHAIR POSITION

 Sitting position offers optimal operating conditions for some neurosurgery

and shoulder surgeries.
 The neurosurgical sitting position may involve the operating table pitched to an
angle of 45 degrees with further neck flexion to allow cranial access, the head is
supported by cranial pins.
 Advantages: good surgical exposure and decreased blood loss.
4.6 SITTING - PHYSIOLOGIC EFFECTS

 Reduced venous return and elevation of the brain above the heart increase the
incidence of hypotension and cerebral hypoperfusion.
 Functional residual capacity and lung compliance increase in the sitting
position.
 Excessive neck flexion or rotation must be avoided as tongue swelling and vessel
kinking may result.
 Arms should be supported in padded gutters to avoid brachial plexus and shoulder
traction injury.
4.6 SITTING - (VAE)

 Venous air embolism:

• Occurs more likely in sitting position especially during neurosurgery.

• Hypoxia, hypotension, cardiac arrhythmias and cardiac arrest may result from
VAE.
• VAE has been reported in the range of 25-75 % during neurosurgical procedures in
the sitting position.
• Best monitored by precordial doppler, TEE and capnogrphy.
• Managed by early detection, flooding the surgical field with saline, 100% oxygen,
aspirate CVC if present, hemodynamic stability, possibility of repositioning.
4.7 PRONE POSITION

 The prone position is used for many neurological and spinal surgery procedures
and also for surgery to the perineum, buttocks and lower limb.
 In prone position, abdomen should remain free without compression.
 Head remains in neutral position, or supported with cranial pins.
 Eyes should be free from pressure.
 Pressure contact areas and bony prominences should be protected.
 Airway should be secured before turning to prone and air entry checked
after then.
4.7 PRONE POSITION - PHYSIOLOGIC EFFECTS

 Reduced cardiac output due reduction in venous return

 Abdomen compression leads to vena caval compression leading to venous stasis
and engorgement of epidural venous plexus.
 Abdominal compression can lead to cephalad displacement of diaphragm with
subsequent hypoxemia, reduced pulmonary compliance and increased peak
airway pressure.
 Postoperative visual loss is associated with longer duration of prone position,
hypotension and venous and face congestion.
 The arms should be abducted to no more than 90°, with slight internal rotation and
lie in front of the plane of the body to reduce the risk of brachial plexus injury.

 Particular attention should be paid to the ulnar nerve at the elbow which is at risk of
pressure-related injury when the arms are flexed.

 Soft tissue compression needs attention, particularly the risk of ischaemia to

breast or male genital area.
5. SUMMARY AND RECOMMENDATIONS

 Positioning the patient during anesthesia is a shared responsibility among the care
providers in the operating room.
 All positions can cause cardiovascular and pulmonary physiologic changes, which
may be exacerbated by anesthesia.
 Goals for positioning should include avoidance of compression and stretch of
neurovascular structures, to minimize the risk of nerve injury.
 Pressure redistribution is the most important factor in preventing pressure induced
injury and may be accomplished by the use of pressure-reducing surfaces and
padding, particularly over bony prominences.
THANK
YOU