Patient Positioning

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Patient PositioningPatient Positioning

Dr. Shailendra.V.L.Dr. Shailendra.V.L.

Specialist in Anesthesia,Specialist in Anesthesia,

Al Bukariya general hospital.Al Bukariya general hospital.

April 8, 2023April 8, 2023 22

Introduction Introduction

Important to know the various implications of Important to know the various implications of patient positioning during surgerypatient positioning during surgery

Because of the various physiological effects it Because of the various physiological effects it exerts on the systemsexerts on the systems

In the last 2 decades newer surgical techniques In the last 2 decades newer surgical techniques developed due to advances developed due to advances In electronicsIn electronics In technology as a wholeIn technology as a whole Better understanding of physiologyBetter understanding of physiology

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Goal of positioningGoal of positioning

Goal of surgical positioning is to facilitate Goal of surgical positioning is to facilitate surgeon’s technical approach while balancing surgeon’s technical approach while balancing risk factorsrisk factors

All surgical positions have position-related All surgical positions have position-related risks risks

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Physiologic effects of change from Physiologic effects of change from vertical to horizontal positionvertical to horizontal position

Body responses to alteration of positions is Body responses to alteration of positions is due to gravitydue to gravity

Effects of Gravity:Effects of Gravity: On blood in venous / arterial / pulmonary systemsOn blood in venous / arterial / pulmonary systems On pulmonary mechanicsOn pulmonary mechanics On pulmonary perfusionOn pulmonary perfusion

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Erect position to Supine positionErect position to Supine position

Cardiac output ↑ on assuming supine positionCardiac output ↑ on assuming supine position Venous blood from lower bodyVenous blood from lower body ↓ ↓ flows backflows back To heartTo heart ↓ ↓ Stretches atrial wallStretches atrial wall ↓ ↓ (Laplace’s law)(Laplace’s law) Stroke volume ↑Stroke volume ↑ ↓ ↓ ↑ ↑ blood pressure blood pressure (clinically normal BP observed)(clinically normal BP observed)

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Baroreceptors in Aorta Baroreceptors in Carotid Baroreceptors in Aorta Baroreceptors in Carotid

↓ ↓ via ↓ via sinusvia ↓ via sinus

Vagus nerve Glossopharyngeal nerveVagus nerve Glossopharyngeal nerve

Medulla OblongataMedulla Oblongata

↓ ↓ efferentefferent

↑ ↑ Parasympathetic activityParasympathetic activity

↓ ↓

↓ ↓ HR ↓SV ↓ContractilityHR ↓SV ↓Contractility

↓ ↓

Little change in BP notedLittle change in BP noted

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Erect posture effect on pulmonary Erect posture effect on pulmonary systemsystem

Abdominal contents & diaphragm move Abdominal contents & diaphragm move caudallycaudally

FRC ↑ TLC ↑FRC ↑ TLC ↑

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Supine posture effect on pulmonary Supine posture effect on pulmonary systemsystem

Abdominal contents move cephaladAbdominal contents move cephalad FRC ↓ TLC ↓FRC ↓ TLC ↓

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Supine positionSupine position

Commonest position for most of the surgeriesCommonest position for most of the surgeries Care should be exercised to prevent injuries to Care should be exercised to prevent injuries to

the anesthetized patientthe anesthetized patient

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Supine position – Pressure pointsSupine position – Pressure points

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Arm tucking in supine positionArm tucking in supine position

One arm if needed to keep by the side of the patientOne arm if needed to keep by the side of the patient , the draw , the draw sheet should cover the arm as shown & tucked under the sheet should cover the arm as shown & tucked under the patient to prevent injury to brachial plexuspatient to prevent injury to brachial plexus

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Arm tucking Arm tucking

Note the arms is tucked using draw sheet & arm is secured by the side

of the patient

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Lithotomy Lithotomy

Used in gynecology & urology proceduresUsed in gynecology & urology procedures Elevation of legs promotes translocation of Elevation of legs promotes translocation of

vascular volume centrallyvascular volume centrally Areas supporting weight of legs prone for Areas supporting weight of legs prone for

nerve injurynerve injury Legs supported at knee & suspended by Legs supported at knee & suspended by

stirrupsstirrups

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Lithotomy positioning - ILithotomy positioning - I

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Lithotomy positioning - IILithotomy positioning - II

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Final lithotomy positionFinal lithotomy position

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Lithotomy position with stirrups Lithotomy position with stirrups

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Lithotomy positionLithotomy position

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Urology -- Lithotomy positionUrology -- Lithotomy position

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Various types of Lithotomy stirrups Various types of Lithotomy stirrups

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Nerve injuries in lithotomyNerve injuries in lithotomy

Peroneal nerve injuryPeroneal nerve injury Saphenous nerve injurySaphenous nerve injury Femoral nerve injuryFemoral nerve injury Obturator nerve injuryObturator nerve injury

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Lithotomy position – Nerve injuriesLithotomy position – Nerve injuries

Peroneal nerve

Saphenous nerve

Femoral nerveObturator nerve

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Lithotomy – nerve injuriesLithotomy – nerve injuries

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Nerve injuries in lithotomyNerve injuries in lithotomy Peroneal nerve injury: Peroneal nerve injury:

Pressure of head of fibula by bar or support Pressure of head of fibula by bar or support structures compresses nervestructures compresses nerve

Saphenous nerve injury:Saphenous nerve injury: Pressure on medial condyle of tibia compress nervePressure on medial condyle of tibia compress nerve

Femoral nerve injury:Femoral nerve injury: Due to angulation of thigh such that inguinal Due to angulation of thigh such that inguinal

ligament is stretched & compresses nerveligament is stretched & compresses nerve Obturator nerve injury:Obturator nerve injury:

Due to greater degree of thigh flexion there is Due to greater degree of thigh flexion there is stretching of nerve as it exits the obturator foramenstretching of nerve as it exits the obturator foramen

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Lithotomy position - problemsLithotomy position - problems

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Compartment syndrome in lower Compartment syndrome in lower limbs during lithotomy positionlimbs during lithotomy position

Long duration of lithotomy positionLong duration of lithotomy position Tightening of leg strapsTightening of leg straps Dorsi-flexion of ankleDorsi-flexion of ankle Surgeon leaning on suspended leg for long Surgeon leaning on suspended leg for long

durationduration

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Upper limb injury during lithotomy Upper limb injury during lithotomy positionposition

Compartment syndrome of hand occurs when Compartment syndrome of hand occurs when hand is tucked under the buttocks & OR tablehand is tucked under the buttocks & OR table

Extension of upper limb > 90* causes traction Extension of upper limb > 90* causes traction of brachial plexusof brachial plexus

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Chemical burns in lithotomy positionChemical burns in lithotomy position

Rare fortunatelyRare fortunately Pooling of preparation solutions at buttock & Pooling of preparation solutions at buttock &

lower back causes chemical burnslower back causes chemical burns

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Lateral positionLateral position

A pad placed under the headA pad placed under the head Arm perpendicular to torso, either on pillow or Arm perpendicular to torso, either on pillow or

an over arm restan over arm rest Pillow between the legsPillow between the legs Arm taped on this positionArm taped on this position Care taken that tape does not press ulnar nerve Care taken that tape does not press ulnar nerve

@ elbow or radial nerve @ radial groove@ elbow or radial nerve @ radial groove

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Higher chest exposure in lateral Higher chest exposure in lateral positionposition

Arm kept in more anterior plane to body to Arm kept in more anterior plane to body to prevent stretching of brachial plexusprevent stretching of brachial plexus

Lower chest supported by axillary roleLower chest supported by axillary role Supports weight of thoraxSupports weight of thorax Prevents compression of shoulder & axillaPrevents compression of shoulder & axilla Prevents brachial plexus injury in axillaPrevents brachial plexus injury in axilla

Palpate Radial artery of dependent arm to Palpate Radial artery of dependent arm to ensure there is no compressionensure there is no compression

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Lateral position with kidney bridgeLateral position with kidney bridge

This position is used for surgeries on the This position is used for surgeries on the kidney & ureterskidney & ureters

Kidney bridge is elevated & this opens up the Kidney bridge is elevated & this opens up the retro pelvic space for optimal exposureretro pelvic space for optimal exposure

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Lateral position with kidney bridgeLateral position with kidney bridge

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Lateral oblique Lateral oblique Three quarters prone positionThree quarters prone position

Used for exposure of posterior cranial fossaUsed for exposure of posterior cranial fossa Head rotated from supine to lateralHead rotated from supine to lateral Head holder pins are insertedHead holder pins are inserted Upper leg is bought forward & flexed slightlyUpper leg is bought forward & flexed slightly Lower leg is left straightLower leg is left straight Axillary role placed under chest to support weight of bodyAxillary role placed under chest to support weight of body Lower shoulder bought to forward edge of bed or just Lower shoulder bought to forward edge of bed or just

slightly over itslightly over it Upper arm placed downward near the side comfortablyUpper arm placed downward near the side comfortably Patient looks like he is trying to look at the floorPatient looks like he is trying to look at the floor

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Lateral oblique positionLateral oblique position

Surgeon

Assistant

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SurgeonAssistant

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Surgeon Assistant

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Problems in lateral oblique positionProblems in lateral oblique position

In obese patients difficulty in placing lower In obese patients difficulty in placing lower arm below torsoarm below torso

Cause considerable weight on humeral head & Cause considerable weight on humeral head & acromionacromion

Lower breast can get compressed – pressure Lower breast can get compressed – pressure on nipple & areolaon nipple & areola

Extreme neck flexion cause cervical spinal Extreme neck flexion cause cervical spinal cord hypo-perfusioncord hypo-perfusion

ECG electrodes can cause pressure necrosisECG electrodes can cause pressure necrosis

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Prone positionProne position

Lumbar LaminectomyLumbar Laminectomy Spinal instrumentationSpinal instrumentation

Steffi’s platingSteffi’s plating Harrington’s rodHarrington’s rod

Pilonidal sinus excision Pilonidal sinus excision

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Prone position - problemsProne position - problems

Careful positioning from supine positionCareful positioning from supine position Prevent pressure on abdomenPrevent pressure on abdomen Prevent pressure on eyesPrevent pressure on eyes Pillows to rest the lower limbsPillows to rest the lower limbs Prevent pressure on male external genitaliaPrevent pressure on male external genitalia

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Prone position – induction on trolley Prone position – induction on trolley

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Prone position Ist stageProne position Ist stage

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Prone position Prone position

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Prone positionProne position

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Prone position Prone position

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Prone position with laminectomy Prone position with laminectomy frame - pressure pointsframe - pressure points

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Trendlenberg’ s positionTrendlenberg’ s position

Modification of supine positionModification of supine position Places head down along with the whole bodyPlaces head down along with the whole body Advantages of this position:Advantages of this position:

Moves viscera cephaladMoves viscera cephalad Helpful in lower abdominal surgeriesHelpful in lower abdominal surgeries To ↑ venous return after spinal anesthesiaTo ↑ venous return after spinal anesthesia To ↑ central blood volume to facilitate central vein To ↑ central blood volume to facilitate central vein

cannulationcannulation To minimize aspiration during regurgitation To minimize aspiration during regurgitation

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Effects of Trenlenberg’ s positionEffects of Trenlenberg’ s position

↑ ↑ CVPCVP ↑ ↑ ICPICP ↑ ↑ IOPIOP ↑ ↑ myocardial workmyocardial work ↑ ↑ pulmonary venous pressurepulmonary venous pressure ↓ ↓ pulmonary compliancepulmonary compliance ↓ ↓ FRCFRC Swelling of face, eyelids, conjunctiva & tongueSwelling of face, eyelids, conjunctiva & tongue

observed in long surgeriesobserved in long surgeries

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Trendlenburg positionTrendlenburg position

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Reverse Trenlenberg’s positionReverse Trenlenberg’s position

This is the opposite of Trenlenberg’s positionThis is the opposite of Trenlenberg’s position This position places head end up & feet downThis position places head end up & feet down This position helps in caudal movement of This position helps in caudal movement of

abdominal contentsabdominal contents Used in upper abdominal laparoscopic Used in upper abdominal laparoscopic

surgeries – Lap gastric bandingsurgeries – Lap gastric banding Causes venous pooling in lower limbs Causes venous pooling in lower limbs To prevent DVT stockings is a mustTo prevent DVT stockings is a must

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Reverse Trenlenberg positionReverse Trenlenberg position

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Jack knife position ( Kraske )Jack knife position ( Kraske )

Used for anal surgeries, pilonidal sinus Used for anal surgeries, pilonidal sinus excisionexcision

Places patient prone with head & feet at a Places patient prone with head & feet at a lower levellower level

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Jack knife positionJack knife position

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Knee chest positionKnee chest position

Further exaggeration of knee-chest positionFurther exaggeration of knee-chest position Used for sigmoidoscopies or lumbar Used for sigmoidoscopies or lumbar

laminectomieslaminectomies Severe hypotension is seen due to pooling of Severe hypotension is seen due to pooling of

blood in the legsblood in the legs

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Knee chest position – pressure pointsKnee chest position – pressure points

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Orthopedic surgeries positionsOrthopedic surgeries positions Orthopedic fracture table – Wattson-Jone’s Orthopedic fracture table – Wattson-Jone’s

Body section to support head & thoraxBody section to support head & thorax Sacral plate for pelvisSacral plate for pelvis Perineal postPerineal post Adjustable foot platesAdjustable foot plates

Table maintains traction of the extremityTable maintains traction of the extremity Allows surgical & fluroscopic accessAllows surgical & fluroscopic access Anesthesia induced & then the patients are positioned Anesthesia induced & then the patients are positioned

on this table (pain)on this table (pain) Arm on # side placed so that it will not interfere with Arm on # side placed so that it will not interfere with

surgical accesssurgical access

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Orthopedic surgeries needing Orthopedic surgeries needing Wattson-Jone’s tableWattson-Jone’s table

# shaft femur for Interlocking# shaft femur for Interlocking DHS with plateDHS with plate Inter-trocanteric # femurInter-trocanteric # femur

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Wattson Jone’s table used for Ortho Wattson Jone’s table used for Ortho surgery surgery

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Wattson Jone’s table used for Ortho Wattson Jone’s table used for Ortho surgerysurgery

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Lateral position on Wattson Jone’s Lateral position on Wattson Jone’s tabletable

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Problems with this positionProblems with this position

Brachial plexus injuryBrachial plexus injury Due to > than 90* extension of the upper limbDue to > than 90* extension of the upper limb

Lower extremity compartment syndromeLower extremity compartment syndrome Due to long surgeries & compressionDue to long surgeries & compression

Pudendal nerve injuryPudendal nerve injury Due to pressure of the perineal postDue to pressure of the perineal post

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Positions for shoulder surgeryPositions for shoulder surgery

Beach chair / barber chair / semi-recumbent Beach chair / barber chair / semi-recumbent positionposition

Provides both anterior & posterior access to Provides both anterior & posterior access to shouldershoulder

Provides freely mobile upper limbProvides freely mobile upper limb Endotraheal tube secured well to prevent Endotraheal tube secured well to prevent

accidental extubationaccidental extubation

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Beach chair position for shoulder Beach chair position for shoulder surgery (Semi Fowler position)surgery (Semi Fowler position)

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Sitting position--Fowler positionSitting position--Fowler position

For posterior cranial fossa positionFor posterior cranial fossa position Better surgical exposureBetter surgical exposure Less tissue retraction & damageLess tissue retraction & damage Less bleedingLess bleeding Less cranial nerve damageLess cranial nerve damage More complete resection of lesionMore complete resection of lesion Ready access to airway, chest & extremitiesReady access to airway, chest & extremities Modern monitoring gives early warning of venous Modern monitoring gives early warning of venous

air-embolismair-embolism

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Sitting position - Neuro surgerySitting position - Neuro surgery

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Sitting position – pressure pointsSitting position – pressure points

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Sitting position Sitting position

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Relative contra-indication to sitting Relative contra-indication to sitting positionposition V-P shunt in positionV-P shunt in position

Cerebral-ischemia upright awakeCerebral-ischemia upright awake Patent foramen ovale & R –L shuntPatent foramen ovale & R –L shunt Cardiac instabilityCardiac instability Extremes of agesExtremes of ages Left AP < RAP -------Left AP < RAP -------Platypnea –OrthodeoxiaPlatypnea –Orthodeoxia

Patient becomes deoxygenated on assuming erect Patient becomes deoxygenated on assuming erect positionposition

Arterial gradients reverses on assuming erect Arterial gradients reverses on assuming erect positionposition

These patients open up foramen ovale & VAE can These patients open up foramen ovale & VAE can enter systemic circulationenter systemic circulation

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Problems in sitting positionProblems in sitting position

Venous air embolismVenous air embolism Hypotension (prevented by stockings)Hypotension (prevented by stockings) Arms – if not well supported cause brachial-Arms – if not well supported cause brachial-

plexus stretchingplexus stretching

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Venous air-embolismVenous air-embolism

Most feared complication in sitting positionMost feared complication in sitting position With subsequent PAE to the brainWith subsequent PAE to the brain

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Air embolismAir embolism

Right atrium with Right atrium with air embolus air embolus

CVP catheter in CVP catheter in situsitu

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Air – embolism monitor warningsAir – embolism monitor warnings

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Mandatory monitoringMandatory monitoring

EKGEKG BPBP SpO2SpO2 EtCO2EtCO2 DopplerDoppler CVPCVP Pulmonary artery catheterPulmonary artery catheter

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Pre-cordial Doppler devicePre-cordial Doppler device

Most advocated monitoringMost advocated monitoring Reasonably pricedReasonably priced Relatively easy to useRelatively easy to use Non-invasiveNon-invasive SensitiveSensitive Sounds heard both by surgeons & Sounds heard both by surgeons &

anesthesiologistanesthesiologist

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Mechanism of peripheral nerve Mechanism of peripheral nerve injury injury

2 basic forces impairing nerve function2 basic forces impairing nerve function Nerves that course superficially for long distances Nerves that course superficially for long distances

are prone for stretch injuryare prone for stretch injury Nerve that pass over bony structures over small Nerve that pass over bony structures over small

area prone for compressionarea prone for compression Final result – nerve ischemia – nerve injuryFinal result – nerve ischemia – nerve injury Ischemia > 30 minutes result in nerve palsyIschemia > 30 minutes result in nerve palsy

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Types of nerve injuryTypes of nerve injury

NeuropraxiaNeuropraxia AxonotomasisAxonotomasis Neurotomasis Neurotomasis

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Neuropraxia Neuropraxia

Occurs with loss of functionOccurs with loss of function Without demonstrable anatomic injuryWithout demonstrable anatomic injury Related to positioning under anesthesiaRelated to positioning under anesthesia Recovery complete in 6 weeksRecovery complete in 6 weeks

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Axonotomesis Axonotomesis

Occurs with anatomic disruption of axons but Occurs with anatomic disruption of axons but preservation of nerve sheath & connective preservation of nerve sheath & connective tissuetissue

Axon degenerates distal to lesionAxon degenerates distal to lesion Regenerates @1mm / dayRegenerates @1mm / day Function gradually returns but in longer nerves Function gradually returns but in longer nerves

of upper limb will take upto 1 yearof upper limb will take upto 1 year Physical therapy helpful to prevent Physical therapy helpful to prevent

degeneration of joints & musclesdegeneration of joints & muscles

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Neurometesis Neurometesis

Results in axon, sheath & connective tissue Results in axon, sheath & connective tissue disruptiondisruption

Leads to degeneration of axon distal to injuryLeads to degeneration of axon distal to injury

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Course of Upper limb nervesCourse of Upper limb nerves

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Brachial plexus in the axillaBrachial plexus in the axilla

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Coarse of nerves in thighCoarse of nerves in thigh

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Coarse of nerves in leg Coarse of nerves in leg

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Cubital-tunnel external compression Cubital-tunnel external compression syndromesyndrome

Ulnar nerve passes through cubital tunnel of Ulnar nerve passes through cubital tunnel of elbowelbow

Forearm pronated will cause compression of Forearm pronated will cause compression of ulnar nerveulnar nerve

Flexion @ elbow > 90* tenses arcuate Flexion @ elbow > 90* tenses arcuate ligament & reduces the tunnel size & ligament & reduces the tunnel size & compress nervecompress nerve

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Ulnar nerve injuryUlnar nerve injury

Pronated arm

Unpadded elbow

Supinated arm

Elbow padded

Ulnar nerve pressure

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Ulnar nerve @ cubital fossaUlnar nerve @ cubital fossa

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Eye injuryEye injury

Excessive pressure on eyes Excessive pressure on eyesExcessive pressure on eyes Excessive pressure on eyes ↓ ↓ > than> than ↓ ↓ more than Arterial pressure more than Arterial pressure

↓ ↓ Venous pressure Arterial inflow ↓Venous pressure Arterial inflow ↓ ↓ ↓ ↓ ↓ Venous collapse Ischemia to RetinaVenous collapse Ischemia to Retina ↓ ↓Arterial inflow goes on Arterial inflow goes on ↓ ↓Arterial haemorrhage occursArterial haemorrhage occurs

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Eye injury Eye injury

Corneal abrasion due to physical injury occursCorneal abrasion due to physical injury occurs Taping of eyelids after instillation of artificial Taping of eyelids after instillation of artificial

tears will prevent this tears will prevent this

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Eye injuryEye injury

Horse shoe rest Horse shoe rest for the headfor the head

Note no pressure Note no pressure on the eyeson the eyes

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Summary Summary

All the team members should All the team members should be familiar with possible risks be familiar with possible risks to maintain patient safetyto maintain patient safety

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Summary Summary

1.1. Make sure the OR table will permit the Make sure the OR table will permit the positionposition

2.2. Gather all positioning accessories before the Gather all positioning accessories before the patient arrives to ORpatient arrives to OR

3.3. Check with the anesthesia provider prior to Check with the anesthesia provider prior to moving the patientmoving the patient

4.4. Provide the number of personnel needed Provide the number of personnel needed 5.5. Use slow movements & do not drag the Use slow movements & do not drag the

patient. Move with a team approachpatient. Move with a team approach

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Summary Summary

6.6. Pad all bony points adequatelyPad all bony points adequately

7.7. Protect all superficial nervesProtect all superficial nerves

8.8. Ensure that the legs are not crossed to Ensure that the legs are not crossed to prevent pressure on nerves or blood vesselsprevent pressure on nerves or blood vessels

9.9. Secure the patient to OR bed properly to Secure the patient to OR bed properly to prevent slippingprevent slipping

10.10. Maintain patient dignity & privacy by Maintain patient dignity & privacy by avoiding unnecessary exposureavoiding unnecessary exposure

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Patient Positioning

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