PATIENT POSITIONING

UMAIRA FATHIMA.M
TUTOR
ANAESTHESIA DEPT.
 INTRODUCTION

• Patient positioning is a major

responsibility that is shared by the entire
operating room team.
• A balance between optimal surgical
positioning and patient well-being is
important
 GOAL OF POSITIONING

• Goal of surgical positioning is to

facilitate surgeon’s technical approach
while balancing risk factors
• All surgical positions have position-
related risks
PHYSIOLOGIC EFFECTS OF CHANGE FROM
VERTICAL TO HORIZONTAL POSITION

• Most changes are related to gravitational effects

on cardiovascular system and respiratory system
• Changes in position redistribute blood within
the venous, arterial and pulmonary vasculature
• Pulmonary mechanism also changes
VARIOUS POSITIONS IN SURGERIES
Cardiac output↑on assuming supine position

Venous blood from lower body

Flows back to heart

Stretches atrial wall

Stroke volume↑

Blood pressure↑
Standing •Abdominal contents &
diaphragm move caudally

position •FRC ↑ TLC ↑

Supine •Abdominal contents move cephalad

•FRC ↓ TLC ↓

position
Supine
•Horizontal, Lawn chair position, Frog leg
position,Trendelenbergposition,
reversetrendelenburgposition

Lithotomy •Standard, Low, High, Exaggerated

Lateral
•Lateral position with kidney
bridge.Lateral Oblique

•Full prone, prone jack-knife, Prone

Prone kneeling

Sitting •Beach chair

SUPINE POSITION
 SUPINE POSITION

• Commonest position for most of the surgeries

• The patient lies on his back
Associated arm position:

• Arms either on arm boards abducted <90° to

minimize the likelihood of brachial plexus
injury
• When arms are adducted, they are usually held
alongside the body with a draw sheet that
passes under the body
• The elbows and any protruding objects, such as
IV lines are padded.
ARM TUCKING IN SUPINE POSITION
 SUPINE CONCERNS
• Greatest concerns are circulation and pressure points
• Most Common Nerve Damage:
• Brachial Plexus: positioning the arm >90*
• Radial and Ulnar: compression against the OR bed, metal
attachments, or when team members lean against the arms
during the procedure
• 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, Calcaneous
PRESSURE POINTS
 SUPINE VARIATION

A. Horizontal
B. Lawn Chair Position
C. Frog leg position
D. Trendelenberg position
E. Reverse trendelenburg position
 B. LAWN CHAIR POSITION

• Back of the bed is raised

• Legs below the knees
are lowered to an
equivalent angle
• Slight trendelenburg
tilt
 C. FROG LEG POSITION

• Hips and knees are flexed and the hips are externally
rotated with soles of feet facing each other
• Allows access to perineum, medial thighs, genitalia and
rectum
 D. TRENDELENBURG POSITION

• Trendelenburg position is tilting a supine patient

head down
• It is often used to increase venous return during
hypotension, to improve exposure during
abdominal and laparoscopic surgery, and to
prevent air emboli and facilitate cannulation
during central line cannulation.
• The Trendelenburg position has significant cardiovascular
and respiratory consequences.
• Increases 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 decreases functional residual capacity 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 above the glottis.
Endotracheal intubation is often preferred to
protect the airway from pulmonary aspiration
related to reflux and to reduce atelectasis.
• Because of the risk of edema to the trachea and
mucosa surrounding the airway during
surgeries in which patients have been in the
Trendelenburg position for prolonged periods,
it may be prudent to verify an air leak around
the endotracheal tube or visualize the larynx
before extubation
 EFFECTS OF TRENLENBERG’ S
POSITION
• ↑ CVP
• ↑ ICP
• ↑ IOP
• ↑ myocardial work
• ↑ pulmonary venous pressure
• ↓ pulmonary compliance
• ↓ FRC
• Swelling of face, eyelids, conjunctiva & tongue observed in
long surgeries
 E. REVERSE TRENDELENBURG POSITION

• Reverse Trendelenburg position (head-up tilt) is often

employed to facilitate upper abdominal surgery by
shifting the abdominal contents caudad.
• Monitoring of arterial blood pressure may be prudent to
detect hypotension owing to decreased venous return.
• In addition, the position of the head above the heart
reduces perfusion pressure to the brain and should be
taken into consideration when determining optimal blood
pressure.
 COMPLICATIONS- SUPINE AND ITS
VARIANTS
• Pressure alopecia, Backache
• Tissues overlying all bony prominences, such as the heels and
sacrum, must be padded to prevent soft tissue ischemia owing to
pressure, especially during prolonged surgery.
• Peripheral nerve injury: Ulnar neuropathy is the most common
• Regardless of the position of the upper extremities, maintaining the
head in a relatively midline position can help minimize the risk of
stretch injury to the brachial plexus.
• ASA practice Advisory recommends limiting arm abductionin supine
patient to less than 90 degrees at the shoulder with the hand and
forearm either supinated or kept in neutral position
PRONE POSITION
 PRONE POSITION

• Used primarily for surgical access to the posterior

fossa of the skull, the posterior spine, the buttocks
and perirectal area, and the lower extremities.
• Careful positioning from supine position
• Prevent pressure on abdomen
• Prevent pressure on eyes
• Pillows to rest the lower limbs
• Prevent pressure on male external genitalia
PRONE POSITION
PRESSURE POINTS
• When general anesthesia is planned, the patient is first intubated
on the stretcher, and all intravascular access is obtained as
needed.
• The endotracheal tube is well secured to prevent dislodgment and
loosening of tape owing to drainage of saliva when prone.
• With the coordination of the entire operating room
staff(minimum of 5), the patient is turned prone onto the
operating room table, keeping the neck in line with the spine
during the move. The anesthesiologist is primarily responsible for
coordinating the move and for repositioning of the head.
• It is recommended to disconnect blood pressure cuffs and arterial
and venous lines that are on the side that rotates furthest to avoid
dislodgment.
• Full monitoring should be reinstituted as rapidly as possible.
• Endotracheal tube position and adequate ventilation are
reassessed immediately after the move
• Because the abdominal wall is easily displaced, external
pressure on the abdomen may elevate intra- abdominal
pressure in the prone position.
• External pressure on the abdomen may push the
diaphragm cephalad, decreasing functional residual
capacity and pulmonary compliance, and increasing peak
airway pressure.
• Abdominal pressure also may impede venous return
through compression of the inferior vena cava
• As such careful attention must be paid to the ability of the
abdomen to hang free and to move with respiration.
• The prone position presents special risks for morbidly
obese patients, whose respiration is already compromised,
and who may be difficult to reposition quickly.
PRONE POSITION WITH LAMINECTOMY
FRAME - PRESSURE POINTS
 COMPLICATIONS

• Airway • Accidental extubation

• Obstruction of ETT bloody secretions/ sputum plugs
• Facial, Airway edema
• Prolonged head low position, ↑ crystalloid infusion
• Problems with extubation
• Visual loss
• Neck injury
• Excessive lateral torsion or hyperflexion → Post-op pain, cervical nerve
root or vascular compression
• Accentuation of pre-existing trauma
• Multiple skeletal injuries may be further exacerbated during positioning
 PRONE VARIATION

A. Full prone Position

B. prone jack-knife Position
C. Prone kneel- Chest Position
 B. JACK KNIFE POSITION

• Used for anal surgeries, pilonidal sinus excision

• Places patient prone with head & feet at a lower level
 C. KNEE CHEST POSITION

• Further exaggeration of jack kinfe position

• Used for sigmoidoscopies or lumbar laminectomies
• Severe hypotension is seen due to pooling of blood in the legs
LITHOTOMY POSITION
 LITHOTOMY POSITION

• The classic lithotomy position is frequently used during

gynecologic, rectal & urologic surgeries.
• The hips are flexed 80° to
100 ° from the trunk & the
legs are abducted 30 ° to 40°
from the midline
• Initiation of the lithotomy position
requires coordinated positioning of
the lower extremities by two
assistants to avoid torsion of the
lumbar spine.
• Both legs should be raised together,
flexing the hips and knees

simultaneously.
• After the surgery, the patient must
be returned to the supine position in
a coordinated manner.
• The legs should be removed from
the holders simultaneously, knees
brought together in the midline, and
the legs slowly straightened and
lowered onto the operating room
 LITHOTOMY VARIATION

A. Standard
B. Low
C. High
D. Exaggerated
A. STANDARD LITHOTOMY POSITION
B. LOW LITHOTOMY POSITION
C. HIGH LITHOTOMY POSITION
D. HEMI LITHOTOMY POSITION
E. EXAGGERATED LITHOTOMY POSITION
 VARIOUS LITHOTOMY STIRRUPS AND
ITS HAZARDS
A. Knee Crutch:
• Pressure on peroneal nerve resulting footdrop and
neuropathies
B. Candy Cane:
• Pressure on distal sural and plantar nerves which can cause
neuropathies of the foot
• Hyperabduction may exaggerated flexion and stretch sciatic
nerve
C. Booth Type:
• May produce support more evenly and reduce localized
pressure
 COMPLICATIONS

• When the legs are elevated, preload increases, causing a

transient increase in CO
• In addition, the lithotomy position causes the abdominal
viscera to displace the diaphragm cephalad, reducing lung
compliance & potentially resulting in a decreased TV
• If obesity or a large abdominal mass is present, abdominal
pressure may increase significatly enough to obstruct venous
return to the heart
• Lower extremity compartment syndrome
 The following characteristics of the lithotomy
position are risk factors for the development of
compartment syndrome
• Long duration of lithotomy position
• Tightening of leg straps
• Dorsi-flexion of ankle
• Surgeon leaning on suspended leg for long duration
Upper limb injury during lithotomy position
• Compartment syndrome of hand occurs when hand is
tucked under the buttocks & OR table
• Extension of upper limb > 90* causes traction of
brachial plexus
NERVE INJURIES
Peroneal nerve injury:
• Pressure of head of fibula by bar or support structures
compresses nerve
Saphenous nerve injury:
• Pressure on medial condyle of tibia compress nerve
Femoral nerve injury:
• Due to angulation of thigh such that inguinal
ligament is stretched & compresses nerve
Obturator nerve injury:
• Due to greater degree of thigh flexion there is
stretching of nerve as it exits the obturator foramen
 LATERAL DECUBITUS POSITION

• The lateral decubitus position is used most frequently for

surgery involving the thorax, retroperitoneal structures, or hip.
• The patient’s head must be kept in a neutral position to prevent
excessive lateral rotation of the neck and stretch injuries to the
brachial plexus. (Additional head support may be required )
• The dependent ear should be checked to avoid folding and
undue pressure.
• It is advised to verify that the eyes are securely taped before
repositioning if the patient is asleep
• Anesthetized in supine prior to turning, shoulder & hips
turned simultaneously to prevent torsion of the spine &
great vessels
• Lower leg is flexed at the hip; upper leg is straight
• Head must be in cervical alignment with the spine
• Breasts and genitalia to be free from torsion and pressure
• Axillary roll placed caudal to axilla of the downside arm
(to protect brachial plexus)
• Padding placed under lower leg, to ankle and foot of
upper leg, and to lower arm (palm up) and upper arm
• Pillow placed lengthwise between legs and between arms
(if lateral arm holder is not used)
• Stabilize patient with safety strap, if needed
 LATERAL VARIATION

A. Lateral position with kidney bridge

B. Lateral Oblique
 A. LATERAL POSITION WITH KIDNEY
BRIDGE
• Kidney bridge is elevated & this opens up the retro pelvic
space for optimal exposure
 B. LATERAL OBLIQUE POSITION
(SEMI‐PRONE POSITION)
• Modification of lat. position. Better access to posterior fossa.
• Upper leg is bought forward & flexed slightly. Lower leg is left straight
• Axillary role placed under chest to support weight of body
• Lower shoulder bought to forward edge of bed or just slightly over it
• Upper arm placed downward near the side comfortably
• Patient looks like he is trying to look at the floor Upper arm positioned
along lateral trunk & upper shoulder is taped towards table.
ORTHOPEDIC SURGERIES
POSITIONS
• Orthopedic fracture table – Wattson-Jone’s
• Body section to support head & thorax
• Sacral plate for pelvis
• Perineal post
• Adjustable foot plates
• Table maintains traction of the extremity
• Allows surgical & fluroscopic access
• Anesthesia induced & then the patients are positioned on this
table (pain)
• Arm on # side placed so that it will not interfere with surgical
access
 ORTHOPEDIC SURGERIES NEEDING
WATTSON-JONE’S TABLE
• # shaft femur for Interlocking
• DHS with plate
• Inter-trocanteric # femur
LATERAL POSITION ON WATTSON
JONE’S TABLE
POSITIONS FOR SHOULDER SURGERY

• Beach chair / barber chair /

semi-recumbent position
• Provides both anterior &
posterior access to shoulder
• Provides freely mobile upper
limb
• Endotracheal tube secured
well to prevent accidental
extubation
SITTING POSITION--FOWLER POSITION

• The sitting position ( although infrequently used because of

the perception of risk from venous and paradoxical air
embolism, offers advantages to the surgeon in approaching the
posterior cervical spine and the posterior fossa.)
• The main advantages of the sitting position over the prone
position for neurosurgical and cervical spine surgeries are;
• excellent surgical exposure
• decreased blood in the operative field
• reduced perioperative blood loss.
• superior access to the airway, reduced facial swelling, and improved
ventilation, particularly in obese patients.(to the anesthesiologist)
For posterior cranial fossa position
• Better surgical exposure
• Less tissue retraction & damage
• Less bleeding
• Less cranial nerve damage
• More complete resection of lesion
• Ready access to airway, chest & extremities
• Modern monitoring gives early warning of venous air
embolism
SITTING POSITION – PRESSURE POINTS
• Because of the elevation of the surgical field above the heart,
and the inability of the dural venous sinuses to collapse
because of their bony attachments, the risk of venous air
embolism is a constant concern.
• Arrhythmia, desaturation, pulmonary hypertension, circulatory
compromise, or cardiac arrest may occur if sufficient
quantities are entrained.
Potential complications from sitting position
• Venous air emboli.
• Need to take measures to detect and extract VAE
• Hypotension.
• Brainstem manipulations resulting in hemodynamic changes.
• Risk of airway obstruction.
• Macroglossia.
• Pneumocephalus
• Quadriplegia.
 VENOUS AIR EMBOLISM

• Air in the venous circulation occluding or impeding distal

flow
• Any procedure where the operative site is higher than the
right atrium and where the vasculature is exposed in a
surgical field carries a risk of air embolism.
• A volume of 5ml/kg is considered large enough to cause an
“air-lock” effect in the right ventricular outflow tract, with
resultant cardiovascular collapse due to catastrophic
reduction in cardiac output
Diagnosis:
• The most sensitive tool to detect VAE is transesophageal
echocardiography (TEE). it can detect as low as 0.25 mL of air.
• Precordial Doppler: It is less sensitive than TEE.
• End tidal carbon dioxide (ETCO2) Sudden drop in ETCO2
values after the opening of dura strongly suggests venous air
embolism.
• End tidal nitrogen: Sudden increase in end tidal nitrogen is
more specific for VAE.
• Alveolar dead space, pulmonary artery pressure and CVP can
increase due to blockage of pulmonary circulation.
• ECG may shows arrhythmias.
Clinical signs:
• Hypo tension
• Tachycardia
• Cyanosis
• Mill wheel murmur
• Cardiovascular collapse

Clinical signs appear late in venous air embolism.

The sensitivity of various tests for detection of air

embolism in decreasing order is:
TEE → Precordial Doppler → PAP, ETCO2 ET
nitrogen → CVP → ECG → clinical signs.
AIR – EMBOLISM MONITOR WARNINGS
 MANDATORY MONITORING

• EKG
• BP
• SpO2
• EtCO2
• Doppler
• CVP
• Pulmonary artery catheter
Treatment:
• Ask the surgeon to pack and flood the area with saline, apply wax to cut edges of
bone to prevent further sucking of air.
• Stop nitrous oxide and start 100% oxygen. Nitrous oxide can expand the size of air
embolus.
• Cardiopulmonary resuscitation, if cardiac arrest has occurred.
• Aspirate air through right atrial catheter (CVP catheter). That is why putting a CVP
catheter makes sense in posterior fossa surgery.
• Bilateral jugular venous compression and Trendelenburg position: These maneuvers
by increasing cerebral venous pressure will decrease air entrainment. Same way,
positive end expiratory pressure (PEEP) will also reduce the air entrainment but
avoided by most of the clinicians as it can increase the possibility of paradoxical
embolism.
• Hypotension is to be managed with inotropic support like dopamine or dobutarnine.
• Treat arrhythmias.
• Treat bronchospasm.
• Left lateral position (right chest up) to keep the air on right side of heart ls now
recommended only if right to left shunt is suspected.
• Hyperbaric oxygen to reduce size of air bubble.
• It is helpful if transfer to hyperbaric chamber is done within 8 hours.
 SUMMARY
• Make sure the OR table will permit the position
• Gather all positioning accessories before the patient arrives to OR
• Check with the anesthesia provider prior to moving the patient
• Provide the number of personnel needed
• Use slow movements & do not drag the patient. Move with a team
approach
• Pad all bony points adequately
• Protect all superficial nerves
• Ensure that the legs are not crossed to prevent pressure on nerves
or blood vessels
• Secure the patient to OR bed properly to prevent slipping
• Maintain patient dignity & privacy by avoiding unnecessary
exposure