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7/31/2019 Patient Positioning and Anaesthesia
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PATIENT POSITIONING AND ANAESTHESIA
Anesthesiologists share a critical responsibility for the proper positioning of patientsin the operating room.
Positions deemed optimal for surgery often result in undesirable physiologic changes
1. hypotension from impaired venous return to the heart oxygen
2. desaturation owing to ventilation-perfusion mismatching.
3. peripheral nerve injuries.
During anesthesia care, whenever possible, patients should be placed in a position thatthey would tolerate when awake.
Padded surfaces, lumbar support, and natural joint position are optimal.
The head should remain midline without substantial extension or flexion whenever
possible.
At no time should pressure on the eyes occur.
The duration of more extreme positions, if such are necessary, should be limited as
much as possible.
SUPINE POSITION
The most common position for surgery is the supine, or dorsal decubitus position. Because
the entire body is close to the level of the heart, hemodynamic reserve is best maintained.
Because compensatory mechanisms are blunted by anesthesia, however, even a few degrees
of head-down (Trendelenburg) position or head-up (reverse Trendelenburg) position are
sufficient to cause significant cardiovascular changes.
Physiology
Un-anaesthetised patients
1. Cardiovascular
Complex arterial, venous, and cardiac physiologic responses have evolved to blunt the
effects of positional changes on arterial blood pressure and maintain perfusion to vitalorgans.
As an individual reclines from an erect to a supine position, venous return to the heart
increases as pooled blood from the lower extremities redistributes toward the heart.
Preload, stroke volume, and cardiac output are augmented. The resultant increase in
arterial blood pressure activates afferent baroreceptors from the aorta and within the
carotid sinuses to decrease sympathetic outflow and increase parasympathetic
impulses to the sinoatrial node and myocardium. The result is a compensatory
decrease in heart rate, stroke volume, and cardiac output.
Mechanoreceptors from the atria and ventricle also are activated to decrease
sympathetic outflow to muscle and splanchnic vascular beds. Resulting in lowering of
blood pressure.
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Atrial reflexes are activated to regulate renal sympathetic nerve activity, plasma renin,
atrial natriuretic peptide, and arginine vasopressin levels.
As a result, systemic arterial blood pressure is maintained within a narrow range
during postural changes in the unanesthetized setting.
2. Pulmonary
Spontaneous ventilation results from small negative intrathoracic pressure shiftsduring inspiration owing to diaphragmatic displacement and chest wall expansion.
This pressure decrease also promotes venous return to the thorax by reducing the
pressure in the great veins and right atrium compared with the periphery.
Normal distribution of ventilation is determined by the excursion of the diaphragm,
movement of the chest wall, and compliance of the lung.
When an individual shifts from standing to supine, functional residual capacitydecreases owing to cephalad displacement of the diaphragm. The relative contribution
to ventilation of the chest wall compared with the diaphragm decreases from 30% to
10%.
With spontaneous ventilation in either position, diaphragmatic movement is greatest
adjacent to the most dependent portions of the lung.
The preferential perfusion of the dependent portions is dominated by gravity and ismore in the dorsal pulmonary segments. As a result, the ventilation-perfusion
mismatch is corrected.
Anaesthetised patients
1. Cardiovascular. General anesthesia, muscle relaxation, positive-pressure ventilation, and neuraxial
blockade interfere with venous return, arterial tone, and autoregulatory mechanisms,
leading to uncompensated circulatory effects of changes in position.
The use of spinal or epidural anesthesia causes a significant sympathectomy across allaffected dermatomes, independent of the presence of general anesthesia, reducing
preload and potentially blunting cardiac response if the sympathetic output to the
heart is affected.
Positive-pressure ventilation increases mean intrathoracic pressure, diminishing the
venous pressure gradient from peripheral capillaries to the right atrium. Positive end-
expiratory pressure increases mean intrathoracic pressure further, as do conditions
associated with low lung compliance, such as airways disease, obesity, ascites, and
light anesthesia.
For these reasons, arterial blood pressure is often particularly labile immediately after
the initiation of anesthesia and during patient positioning. It is crucial for the
anesthesiologist to anticipate, monitor, and treat these effects, and to assess the safety
of positional changes for each patient. Blood pressure should be measured frequently
after induction of anesthesia or initiation of neuraxial blockade. It is often necessary
to increase intravenous fluid administration, adjust the level of anesthesia, or
administer vasopressors during this hemodynamic transition. Temporary use of head-
down positions may be helpful.Interruptions in monitoring to facilitate positioning or
turning of the operating room table must be minimized during this dynamic period.
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2. Pulmonary
Anesthetized patients who are breathing spontaneously have a reduced tidal volumeand functional residual capacity and an increased closing volume compared with the
nonanesthetized state.
Positive-pressure ventilation with muscle relaxation may ameliorate ventilation-perfusion mismatches under general anesthesia by maintaining adequate minute
ventilation and limiting atelectasis.
The diaphragm assumes an abnormal shape, however, owing to the loss of muscletone, and is displaced less in the dependent portions of the lung.This causes
ventilation-perfusion mismatching .
Patients undergoing neuraxial anesthesia lose abdominal and thoracic muscle function
in affected dermatomes, but diaphragmatic function is retained.
Complications
1. Pressure alopecia
resulting from ischemic hair follicles is related to prolonged immobilization of the
head with its full weight falling on a limited area, usually the occiput.
Lumps, such as those caused by monitoring cable connectors, should not be placedunder head padding because they may create focal areas of pressure.
Hypothermia and hypotension during surgery, such as during cardiopulmonary
bypass, may increase the incidence of this complication.
Consequently, it is prudent to cushion the head well, and if possible during prolonged
surgery, periodic rotation of the head to redistribute the weight may be considered.
2. Backache
may occur in the supine position as the normal lumbar lordotic curvature, particularlythe tone of the paraspinous musculature, is lost during general anesthesia with muscle
relaxation or a neuraxial block.
Consequently, patients with extensive kyphosis, scoliosis, or a previous history of back pain may require extra padding of the spine or slight flexion at the hip and knee.
3. Pressure ischaemia
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
4. Peripheral nerve injury
is a complex phenomenon with a multifactorial etiology.
Ulnar neuropathy is the most common lesion.
Although there is no direct evidence that positioning or padding alone can prevent
perioperative ulnar neuropathies, it is recommended, to limit arm abduction in a
supine patient to less than 90 degrees at the shoulder with the hand and forearm either
supinated or kept in a neutral position.
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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.
Arm position in Supine position
One or both arms may be abducted out to the side or adducted (tucked) alongside the
body.
It is recommended that upper extremity abduction be limited to less than 90 degrees to
minimize the likelihood of brachial plexus injury by caudad pressure in the axilla
from the head of the humerus.
The hand and forearm are either supinated or kept in a neutral position with the palm
toward the body to reduce external pressure on the spiral groove of the humerus and
the ulnar nerve
When the arms are adducted, they are usually held alongside the body with a ―drawsheet‖ that passes under the body and over the arm, and is then tucked directly under
the torso to ensure that the arm remains properly placed next to the body. Alternatively, in surgeries in which access to the chest or abdomen is not necessary,
curved arm cradles may be used. In all cases, the arms are placed in a neutral
position.[16]
The elbows and any protruding objects, such as intravenous fluid lines
and stopcocks, are padded
Variations of the Supine Position
1. The lawn chair position
the hips and knees are slightly flexed.
reduces stress on the back, hips, and knees, and is better tolerated by patients who areawake or undergoing monitored anesthesia care.
As the legs are slightly above the heart, venous drainage from the lower extremity is
facilitated.
Also, the xiphoid to pubic distance is decreased, reducing the tension on the ventral
abdominal musculature and easing closure of laparotomy incisions.
2. The frog-leg position
the hips and knees are flexed, and the hips are externally rotated with the soles of the
feet facing each other, allows access to the perineum, medial thighs, genitalia, andrectum
. Care must be taken to minimize stress and postoperative pain in the hips and prevent
dislocation by supporting the knees appropriately.
3. Trendelenburg position
Head low position
often used to increase venous return during hypotension, to improve exposure duringabdominal and laparoscopic surgery, and to prevent air emboli and facilitate
cannulation during central line placement
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The Trendelenburg position has significant cardiovascular and respiratory
consequences.
The head-down position 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 airwayobstruction.
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.
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 prolongedperiods, it may be prudent to visualize the larynx before extubation.
4. Reverse Trendelenburg position
head-up tilt
is often employed to facilitate upper abdominal surgery by shifting the abdominal
contents caudad.
Caution is advised to prevent patients from slipping on the table
frequent 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 thebrain and should be taken into consideration when determining optimal blood
pressure.
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LITHOTOMY POSITION
The classic lithotomy position is frequently used during gynecologic, rectal, and
urologic surgeries.
The hips are flexed 80 to 100 degrees from the trunk, and the legs are abducted 30 to
45 degrees from the midline. The knees are flexed until the lower legs are parallel to
the torso, and the legs are held by supports or stirrups. The foot section of the
operating room table is then lowered.
Initiation of the lithotomy position requires coordinated positioning of the lowerextremities by two assistants to avoid torsion of the lumbar spine. Both legs should be
raised together, flexing the hips and knees simultaneously.
The lower extremities should be padded to prevent compression against the stirrups.
After the surgery, the patient must be returned to the supine position in a coordinated
manner.
The hands should be positioned to prevent entrapment in any moving or articulating
sections of the operating room table.
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
table.
Physiological changes.(+ those of supine position)
When the legs are elevated, preload increases, causing a transient increase in cardiacoutput and, to a lesser extent, cerebral venous and intracranial pressure in otherwise
healthy patients.
In addition, the lithotomy position causes the abdominal viscera to displace the
diaphragm cephalad, reducing lung compliance and potentially resulting in a
decreased tidal volume.
If obesity or a large abdominal mass is present (tumor, gravid uterus), abdominal
pressure may increase significantly enough to obstruct venous return to the heart.
Lastly, the normal lordotic curvature of the lumbar spine is lost in the lithotomy
position, potentially aggravating any previous lower back pain.
More acute flexion of the knees or hips can threaten to angulate and compress majorvessels at either joint.
hip flexion to greater than 90 degrees on the trunk has been shown to increase stretch
of the inguinal ligaments.
Complications.(+ those of supine position)
Injury to the common peroneal nerve is the most common lower extremity motorneuropathy. A potential cause of the injury was the compression of the nerve between
the lateral head of the fibula and the bar holding the legs. When the candy cane
stirrups are used, special attention must be paid to avoid compression.The injury was
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more common with patients who had low body mass index, recent cigarette smoking,
or prolonged duration of surgery.
Paresthesias in the distribution of the obturator, lateral femoral cutaneous, sciatic, andperoneal nerves may occur due to nerve compression.
Lower extremity compartment syndrome is a rare complication associated with the
lithotomy position. It occurs when perfusion to an extremity is inadequate, resulting inischemia, edema, and extensive rhabdomyolysis from increased tissue pressure within
a fascial compartment. Long surgical procedure time was the only distinguishing
characteristic of the surgeries in which patients developed lower extremity
compartment syndromes. It is recommended to lower the legs to the level of the body
periodically if surgery extends beyond several hours.
If the arms are on the operating table alongside the patient, the hands and fingers may
lie near the open edge of the lowered section of the table. When raising the foot of the
table at the end of surgery, strict attention to the position of the hand must be paid to
avoid a potentially disastrous crush injury to the fingers.
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LATERAL DECUBITUS POSITION
The lateral decubitus position is used most frequently for surgery involving thethorax, retroperitoneal structures, or hip.
The patient rests on the nonoperative side and is balanced with anterior and posterior
support, such as bedding rolls or a deflatable beanbag, and a flexed dependent leg.
The arms usually are positioned in front of the patient. The dependent arm rests on a
padded arm board perpendicular to the torso. The nondependent arm is often
supported over folded bedding or suspended with an armrest or foam cradle. If
possible, the arm should not be abducted more than 90 degrees.
The patient's head must be kept in a neutral position to prevent excessive lateralrotation of the neck and stretch injuries to the brachial plexus.
The dependent ear should be checked to avoid folding and undue pressure. It isadvised to verify that the eyes are securely taped before repositioning if the patient is
asleep. The dependent eye must be checked frequently for external compression.
To avoid compression injury to the dependent brachial plexus or vascularcompression, an ―axillary roll‖ is frequently placed just caudal to the dependent axilla
This roll should never be placed in the axilla. Its purpose is to ensure that the weight
of the thorax is borne by the chest wall caudal to the axilla and avoid compression of
the axillary contents.
The pulse should be monitored in the dependent arm for early detection of
compression to axillary neurovascular structures. . The act of positioning a patient in the lateral decubitus position requires the
cooperation of the entire operating room staff to prevent potential injuries.
Physiology
1. Circulatory
If the legs are maintained in the long axis of the body, almost no pressure gradients
exist along the great vessels from head to foot. Small hydrostatic differences are
detected between the values when blood pressure is recorded simultaneously on thetwo arms.
If the lower extremities are positioned below the level of the heart, blood pools in the
distensible vessels of the dangling legs because of gravity-induced increases in
venous pressure and resultant venous stasis. Wrapping the legs and thighs in
compressive bandages has been commonly used to combat venous pooling.
Marked flexion of the lower extremities at knees and hips can partially or completely
obstruct venous return to the inferior vena cava either by angulation of vessels at the
popliteal space and inguinal ligament or by thigh compression against an obese
abdomen.
A small support placed just caudad of the down-side axilla can be used to lift thethorax enough to relieve pressure on the axillary neurovascular bundle and prevent
disturbed blood flow to the arm and hand. Any padding should support only the chest
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wall and it should be periodically observed to ensure that it doesn't impinge on the
neurovascular structures of the axilla.
If the cervical spine of the patient who is placed in a horizontal lateral decubitusposition is carefully maintained in alignment with the thoracolumbar spine, almost no
gradient occurs between pressures in the mediastinum and those in the head.
However, if the head is not supported and sufficient lateral angulation of the neck occurs in either direction, obstruction of jugular flow may occur.
In the low-pressure pulmonary circuit, hydrostatic gradients occur between the twohemithoraces. Vascular congestion of the dependent lung and the relative
hypoperfusion of the non dependent lung is noted.
2. Respiratory
In the presence of a supple chest, the lateral decubitus position can decrease the
volume of the dependent hemithorax. The weight of the chest forces the rib cage into
a less expanded conformation. Gravity-induced shifts of mediastinal structures toward
the chest wall tend further to reduce the volume of the dependent lung. Abdominal
viscera force the down-side diaphragm cephalad if the long axis of the trunk is
horizontal or head down.
Spontaneous ventilation can partially compensate for the diaphragmatic stretching in
the dependent hemithorax because the contractile efficiency of the elongated
diaphragmatic muscle fibers is increased.
The non dependent hemithorax is much less compressed than the dependent side, and
because the lung lies above the level of the atria, it has less vascular congestion. As a
result, positive-pressure ventilation is directed preferentially to the more compliant
up-side lung. The result can easily be excessive ventilation of the underperfused up-
side lung and hypoventilation of the congested down-side lung. The potential for aclinically significant ventilation – perfusion mismatch is obvious, particularly in the
presence of pulmonary disease.
Complications
1. Eyes and Ears - Injuries to the dependent eye are unlikely if the head is properly
supported during and after the turn from the supine to the lateral position. If the
patient's face turns toward the mattress, however, and the lids are not closed or the
eyes otherwise protected, abrasions of the ocular surface can occur. Direct pressure onthe globe can displace the crystalline lens, increase intraocular pressure or,
particularly if systemic hypotension is present, cause ischemia.In the lateral position,
the weight of the head can press the down-side ear against a rough or wrinkled
supporting surface. Careful padding with a pillow or a foam sponge is usually
sufficient protection against contusion of the ear. The external ear should also be
palpated to ensure that it has not been folded over in the process of placing support
beneath the head.
2. Neck - Lateral flexion of the neck is possible when the head of a patient in the lateral
position is inadequately supported. If the cervical spine is arthritic, postoperative neck
pain can be troublesome. Pain from a symptomatic protrusion of a cervical disk canbe intensified unless the head is carefully positioned so that lateral or ventral flexion,
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extension, or rotation is avoided. Patients with unstable cervical spines can be
intubated while awake and turned gently into the operative position while repeated
neurologic checks, with which the patient cooperates and responds, are accomplished
to detect the development of a positioning injury.65
3. Suprascapular Nerve - Ventral circumduction of the dependent shoulder can rotate thesuprascapular notch away from the root of the neck this can stretch the suprascapular
nerve and produce troublesome, diffuse, dull shoulder pain. The diagnosis is
established by blocking the nerve at the notch and producing pain relief. Treatment
may require resecting the ligament over the notch to decompress the nerve. A
supporting pad placed under the thorax just caudad of the axilla and thick enough to
raise the chest off the shoulder should prevent a circumduction stretch injury to the
nerve.
4. Long Thoracic Nerve - Instances of postoperative winging of the scapula have
followed use of the lateral decubitus position. There is a possibility of trauma to the
nerve while establishing the lateral position. Lateral flexion of the neck may stretchthe long thoracic nerve in the obtuse angle of the neck.
5. Nerve - The common peroneal nerve of the dependent side is padded to minimize
compression damage caused by the weight of the legs. A small pad, thick enough to
raise the chest wall and prevent excessive compression of the shoulder or
entrapment/compression of the neurovasclar structures of the axilla, is placed just
caudad to the dependent axilla
6. Vascular - Compression and venous engorgement in the dependent arm may affect
the pulse oximetry reading, and a low saturation reading may be an early warning of compromised circulation. Hypotension measured in the dependent arm may be due to
axillary arterial compression, so it is useful to retain the ability to measure blood
pressure in both arms
Variations of the Lateral Decubitus Positions
1. Semisupine and Semiprone
The semilateral postures are designed to allow the surgeon to reach anterolateral
(semisupine) and posterolateral (semiprone) structures of the trunk.
In the semisupine position, the up-side arm must be carefully supported so that it is
not hyperextended and no traction or compression is applied to the brachial and
axillary neurovascular bundles
Noncompressible padding should be placed under the dorsal torso and hip to prevent
the patient from rolling supine and stretching the anchored extremity.
The pulse of the restrained wrist should be checked to ensure adequate circulation in
the elevated arm.
2. Lateral Jackknife.
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The lateral jackknife position places the down-side iliac crest over the hinge between
the back and thigh sections of the table and thetable top is angulated at that point to
flex the thighs on the trunk laterally.
After the patient has been suitably positioned and restrained, the chassis of the table istipped so that the uppermost surface of the patient's flank and thorax becomes
essentially horizontal. As a result, the feet are below the level of the atria, andsignificant amounts of blood may pool in distensible vessels in each leg.
The lateral jackknife position is usually intended to stretch the up-side flank and
widen intercostal spaces as an asset to a thoracotomy incision. However, in terms of
lumbar stress, restriction by the taut flank of up-side costal margin motion, and
pooling of blood in depressed lower extremities, the position imposes a significant
physiologic insult.
3. Kidney.
The kidney position resembles the lateral jackknife position, but it adds the use of
an elevated rest (the kidney rest) under the down-side iliac crest to increase the
amount of lateral flexion and improve access to the up-side kidney under the
overhanging costal margin.
Unlike the lateral jackknife position, the kidney position does not have a useful
alternative for a flank approach to the kidney. Thus, the physiologic insults
associated with the posture need to be limited by vigilant anesthesia and rapid
surgery.
Strict stabilizing precautions should be taken to prevent the patient fromsubsequently shifting caudad on the table in such a manner that the elevated rest
relocates into the down-side flank and becomes a severe impediment to ventilationof the dependent lung.
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PRONE POSITION
The prone or ventral decubitus position is used primarily for surgical access to the
posterior fossa of the skull, the posterior spine, the buttocks and perirectal area, and
the lower extremities.
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, 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 linesthat are on the side that rotates furthest to avoid dislodgment, although some
clinicians prefer to disconnect all lines and monitors before moving. Pulse oximetry
usually can be maintained if applied to the ―inside‖ arm, and full monitoring should
be reinstituted as rapidly as possible. Endotracheal tube position and adequate
ventilation are reassessed immediately after the move.
Head position is crucial. The patient's head may be turned to the side when prone if neck mobility is adequate. As in the lateral decubitus position, the dependent eye must
be checked frequently for external compression. In addition, in patients with cervical
arthritis or cerebrovascular disease, lateral rotation of the neck may compromise
carotid or vertebral arterial blood flow or jugular venous drainage.
In most cases, the head is kept in a neutral position using a surgical pillow, horseshoeheadrest, or Mayfield head pins.
Pillows are specially designed for the prone position. Most, including disposable foam
versions, support the forehead, malar regions, and the chin, with a cutout for the eyes,
nose, and mouth (see Fig. 36-14 ). The face is not always visible making eye checks
more difficult. Mirror systems are available to facilitate intermittent visual
confirmation that the eyes are unimpinged, although direct visualization or tactile
confirmation of at least the initial appearance is prudent
The horseshoe headrest supports only the forehead and malar regions and allows
excellent access to the airway, but it is more rigid and potentially dangerous if the
head moves . Mayfield rigid pins support the head without any direct pressure on the face, allow
access to the airway, and hold the head firmly in one position that can be finely
adjusted for optimal neurosurgical exposure ( Fig. 36-18 ). Rigid pin fixation is rarely
used outside cranial or cervical spine surgeries.
Regardless of the technique employed to support the head, the eyes, face, and airwaymust be checked periodically to ensure that the weight is borne only by the bony
structures, and that there is no pressure on the eyes.
Careful attention must be paid to the ability of the abdomen to hang free and to movewith respiration.
The thorax is generally supported by firm rolls or bolsters placed along each side from
the clavicle to the iliac crest.
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To prevent tissue injury, pendulous structures (e.g., male genitalia and female
breasts) should be clear of compression; the breasts should be placed medial to the
bolsters. The lower portion of each roll or bolster must be placed under its respective
iliac crest to prevent pressure injury to the genitalia and the femoral vasculature.[32]
The prone position presents special risks for morbidly obese patients, whose
respiration is already compromised, and who may be difficult to reposition quickly. The legs should be padded and flexed slightly at the knees and hips.
Both arms may be positioned to the patient's sides and tucked in the neutral position
as described for a supine patient, or placed next to the patient's head on arm boards.
Extra padding under the elbow is needed to prevent compression of the ulnar nerve.
The arms should not be abducted greater than 90 degrees to prevent excessive
stretching of the brachial plexus, especially in patients with the head turned.
Finally, elastic stockings and active compression devices are needed for the lowerextremities to minimize pooling of the blood, especially with any flexion of the body.
Physiology
1. Circulatory
In the prone position, the circulatory dynamics vary according to the postural
modification in use.
If the legs remain essentially horizontal, pressure gradients in the blood vessels areminimal.
If the patient is kneeling, or if the table chassis is rotated head high, significant
pooling of venous blood in distensible dependent vessels is likely to occur. Also as
the head is above the level of the heart, mean vascular pressures are decreased
according to the distance above the heart and conjunctival edema is less evident orabsent, but air entrainment in open veins is possible.
If the head of a prone patient is below the level of the heart, venous congestion of the
face and neck becomes evident. Conjunctival edema is usual and reflects the influence
of gravity on accumulation of extravascular fluid.
With the patient lying on the soft abdominal wall, pressure of compressed viscera is
transmitted to the dorsal surface of the abdominal cavity. Mesenteric and
paravertebral vessels are compressed, causing engorgement of veins within the spinal
canal. Obstruction of the inferior vena cava can produce immediate, visible distention
of vertebral veins.
Turning the patient's head can alter arterial perfusion and venous drainage in both
extracranial and intracranial vessels. No significant changes were detected in mean arterial pressure, right atrial pressure,
or pulmonary artery occlusion pressure.
2. Respiratory
The original areas of compression atelectasis reopen when those parts of the lung
became nondependent, whereas fresh areas of compression atelectasis are formed in
the newly dependent areas of the lung.
No change in oxygenation or shunting when pronation occurred.
If the thorax is supple or compliant, the body weight of an anesthetized, prone patient
compresses the anteroposterior diameter of the relaxed chest. If the essure of the
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abdominal viscera is sufficient to force the diaphragm cephalad, the lung is shortened
along its long axis. Hence, the compliance of the compacted prone lung can be
anticipated to decrease.
The result of decreased pulmonary compliance in a poorly positioned, prone,
anesthetized patient is either an increased work of spontaneous ventilation or the need
for higher inflation pressures during positive-pressure ventilation. Proper positioning can retain more nearly normal pulmonary compliance by
minimizing the cephalad shift of the diaphragm caused by compressed abdominal
viscera. If the patient is arranged so that the abdomen hangs free, the loss of
functional residual capacity is less in the prone position than in either the supine or
the lateral position.
Complications
1. Eyes and Ears - The eyes and ears may sustain injury in the prone position. The
eyelids should be closed, and each eye should be protected in some manner so that the
lids cannot be accidentally separated and the cornea scratched. Instillation of
lubrication in the eyes should be considered, although the value of this treatment is
debated. The eyes should also be protected against the head turning medially after
positioning as well as against pressure being exerted on the globe. Conjunctival
edema usually occurs in the eyes of the pronated patient if the head is at or below the
level of the heart. It is usually transient, inconsequential, and requires only
reestablishment of the normal tissue perfusion gradients of the supine position, or of a
slight amount of head-up tilt, to be redistributed.
2. Blindness - Permanent loss of vision can occur after nonocular surgical procedures,
especially those performed in a ventral decubitus position.The occurrence of thisdevastating complication is particularly associated with extensive surgical procedures
done in the prone position, such as reconstructive spine surgery, where there is
associated blood loss, anemia, and hypotension. Causes of significant permanent
postoperative visual loss usually involve compromise of oxygen delivery to elements
of the visual pathway and include ischemic optic neuropathy (anterior or posterior),
retinal artery occlusion (central or branch), and cortical blindness.
3. Neck Problems - Anesthesia impairs reflex muscle spasm that protects the skeleton
against motion that would be painful if the patient were alert. Lateral rotation of the
head and neck of an anesthetized, pronated patient, particularly one with an arthritic
cervical spine, can stretch relaxed skeletal muscles and ligaments and injure
articulations of cervical vertebrae. Postoperative neck pain and limitation of motioncan result. The arthritic neck is usually best managed by keeping the head in the
sagittal plane when the patient is prone.
4. Vascular - Extremes of head and neck rotation can also interfere with flow in either
the ipsilateral or contralateral vessels to and from the head. Excessive head rotation
can reduce flow in both the carotid and vertebral systems.
5. Nerve Injuries - Stretch injuries to the roots of the brachial plexus.The ulnar nerve,
lying in the cubital tunnel is vulnerable to being compressed by the weight of the
elbow Consequently, the medial aspect of the elbow must be well padded and its
weight borne principally on the medial epicondyle.
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6. Breast Injuries - The breasts of a pronated woman, if forced laterally by ventral chest
supports, can be stretched and injured along their sternal borders. Medial and
cephalad displacement seems better tolerated. Direct pressure on breasts (particularly
if breast prostheses are present) can cause ischemia to breast tissue and should be
avoided.
7. Abdominal Compression - Compression of the abdomen by the weight of the pronepatient's trunk can cause viscera to force the diaphragm cephalad enough to impair
ventilation. If intra-abdominal pressure approaches or exceeds venous pressure, return
of blood from the pelvis and lower extremities is reduced or obstructed. Because the
vertebral venous plexuses communicate directly with the abdominal veins, increased
intra-abdominal pressure is transmitted to the perivertebral and intraspinal surgical
field in the form of venous distention and increased difficulty with hemostasis. All of
the various supportive pads and frames, when properly used, are designed to remove
pressure from the abdomen and avoid these problems.
8. Knee Injuries - Obese patients, or those who have pathologic conditions of the knees,
can have their knee joints injured in the kneeling position if the supportive ledges are
not heavily padded
Variations of the Ventral Decubitus Position
1. Prone Jackknife
The prone jackknife posture is used to provide access to the sacral, perianal, and
perineal areas as well as to the lower alimentary canal.
The thighs are flexed on the trunk more than is usual in the full prone position, with
the table surface hinges determining the degree of flexion achievable.66
2. Prone Kneeling
Kneeling positions have been used to improve operative conditions in the lumbar and
cervicooccipital areas.If the vertebral column is unstable, kneeling frames are not as useful as
parallel longitudinal supports because kneeling risks application of shearing forces at the
fracture site, with the potential for damage of the contents of the spinal canal. In massively
obese patients who must be operated on in the prone position, kneeling frames tend to prevent
pressure on the abdomen more successfully than longitudinal frames.
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Sitting Position
The sitting position 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, and, possibly, reduced perioperative blood loss.
The main advantages to the anesthesiologist are superior access to the airway, reduced
facial swelling, and improved ventilation, particularly in obese patients.
The classic sitting position for surgery places the patient in a semi-reclining posture
on an operating table, with the legs elevated to approximately the level of the heart
and the head flexed ventrally on the neck.
The head may be fixed in pins for neurosurgery or taped in place with adequatesupport for other surgeries.
Head flexion should not be sufficient to force the chin into the suprasternal notch.
Elastic stockings or compressive wraps around the legs reduce pooling of blood in the
lower extremities.
Because gravity is pulling the arms caudad, they must be supported to the point of
slight elevation of the shoulders to avoid traction on the shoulder muscles and
potential stretching of upper extremity neurovascular structures.
The knees are usually slightly flexed for balance and to reduce stretching of the sciatic
nerve, and the feet are supported and padded.
Physiology
1. Cardiovascular
The hemodynamic effects of placing a supine patient in the sitting position are
dramatic.
As the head is raised above the level of the heart, pressure gradients develop and
increase with the degree of elevation.
Blood shifts from the upper body toward the feet. Atrial filling pressures decrease,
sympathetic tone increases, parasympathetic tone decreases, the renin-angiotensin-aldosterone system is activated, and fluid and electrolytes are retained by the kidneys.
Because of the pooling of blood into the lower body under general anesthesia patients
are particularly prone to hypotensive episodes. Incremental positioning and the use of
intravenous fluids, vasopressors, and appropriate adjustments of anesthetic depth can
reduce the degree and duration of hypotension. Elastic stockings and active leg
compression devices can help maintain venous return.
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2. Respiratory
As the patient becomes more upright in the head-elevated dorsal decubitus position,
the inspiratory stroke of the diaphragm becomes less impeded by the bulk of
abdominal viscera.
Spontaneous chest wall motion requires less effort, and less pressure is needed to
inflate the lungs during passive inspiration. Functional residual capacity increases in
the head-elevated positions.
Complications
Postural Hypotension - In the anesthetized patient, establishing any of the head-
elevated positions is frequently accompanied by some degree of reduction in systemic
blood pressure. The normal protective reflexes are inhibited by drugs used duringanesthesia. Measuring mean arterial pressures at the level of the circle of Willis is
recommended to assess cerebral perfusion pressures more accurately.
Air Embolus - 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.Air embolization is potentially
lethal. In the bloodstream, air migrates to the heart, where it creates a compressible
foam that destroys the propulsive efficiency of ventricular contraction and irritates the
conduction system. Air can also move into the pulmonary vasculature, where bubbles
obstruct small vessels and compromise gas exchange, or it can cross through a patent
foramen ovale to the left side of the heart and the systemic circulation.The potential
for venous air embolization increases with the degree of elevation of the operative site
above the heart.
Pneumocephalus - When brain mass is decreased by ventricular drainage, steroids,
and diuresis, the space available after dura is opened, to a pneumocephalus is
enlarged. Diffusion of nitrous oxide into the accumulated air, or the warming of
trapped gas, can produce a tension pneumocephalus with signs of increased
intracranial pressure and delayed awakening from anesthesia.
.Ocular Compression - Pressure from a padded head rest on the eyes of a patient who
has been placed in a head-elevated position can dislocate a crystalline lens or render
the globe ischemic.
Edema of the Face, Tongue, and Neck - Severe postoperative macroglossia,
apparently because of venous and lymphatic obstruction, can be caused by prolonged,
marked neck flexion. Extremes of neck flexion, with or without head rotation, have
been widely used to gain access to structures in the posterior fossa and cervical spine,
but their potential for damage should be understood and excessive flexion – rotation
avoided if possible
Midcervical Tetraplegia - This devastating injury occurs after hyperflexion of the
neck, with or without rotation of the head, and is attributed to stretching of the spinal
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Peripheral Nerve Injury
Peripheral nerve injury remains a serious peri-operative complication.
Injuries occur when peripheral nerves are subjected to stretch, ischemia, or
compression during surgery.
Because sensation is blocked by unconsciousness or regional anesthesia, early
warning symptoms of pain and the normal spontaneous repositioning are absent.
Ulnar neuropathy is the most frequent site of injury (28%), followed by the brachialplexus (20%), lumbosacral nerve root (16%), and spinal cord (13%).
With the exception of spinal cord injury, the mechanism of nerve injury remains
largely unknown. Most injuries, particularly injuries to nerves of the upper extremity,
such as the ulnar nerve and brachial plexus, occurred in the presence of adequate
positioning and padding.
Padding, positional details andprolonged duration are risk factors.
1. Ulnar Nerve
The etiology of perioperative ulnar neuropathy is complex and incompletely
understood.
Injury was thought to be associated with hyperflexion of the elbow and compression
by the operating room table of the nerve at the condylar groove and the cubital tunnel
against the posterior aspect of the medial epicondyle of the humerus.
The neuropathy, if permanent, results in the inability to abduct or oppose the fifth
finger, diminished sensation in the fourth and fifth fingers, and eventual atrophy of
the intrinsic muscle of the hands creating a claw-like hand.
Perioperative ulnar neuropathy occurred predominantly in men, in an older
population, and with a delayed onset.
The large predominance of ulnar injury in men may be explained by anatomic
differences. Men have a more developed and thickened flexor retinaculum with less
protective adipose tissue and a larger (1.5 ×) tubercle of the coronoid process that can
predispose to nerve compression in the cubital tunnel. Other risk factors are diabetes
mellitus, vitamin deficiency, alcoholism, cigarette smoking, and cancer
2. Brachial Plexus
The brachial plexus is susceptible to injury from stretching or compression because of its long superficial course in the axilla between two points of fixation, the vertebra
and the axillary fascia, in association with the mobile clavicle and humerus
The patient often complains of sensory deficit in the distribution of the ulnar nerve.
Injury is most commonly associated with arm abduction greater than 90 degrees,
lateral rotation of the head, asymmetric retraction of the sternum for internal
mammary artery dissection during cardiac surgery, and direct trauma.
To avoid brachial plexus injury, patients ideally should be positioned with the head
midline, arms kept at the sides, the elbow mildly flexed, and the forearm supinated.
Brachial plexus injuries occurred during a regional block, particularly the axillaryblock.
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Brachial plexus injury also is associated with direct compression, particularly with the
use of shoulder braces in patients undergoing surgery in the Trendelenburg position.
The nerves are vulnerable to compression as they pass between the clavicle and the
first rib. Medial placement of the braces can compress the proximal roots, and lateral
placement of the braces can stretch the plexus.
3. Other Upper Extremity Nerves
The radial nerve can be injured from direct pressure as it traverses the spiral groove of the humerus in the lower third of the arm.
The injury often manifests as a wrist drop with an inability to abduct the thumb or
extend the metacarpophalangeal joints.
Isolated median nerve injury most often occurs during the insertion of an intravenous
needle into the antecubital fossa in an anesthetized patient where the nerve is adjacent
to the medial cubital and basilic veins.
Patients with this injury are unable to oppose the first and fifth digits and have
decreased sensation over the palmar surface of the lateral three and a half fingers
4. Lower Extremity Nerves
Injuries to the sciatic and common peroneal nerves occur most often in the lithotomyposition.
Because of its fixation between the sciatic notch and the neck of the fibula, the sciatic
nerve can be stretched with external rotation of the leg. Hyperflexion of the hips or
extension of the knees also can aggravate nerve stretch in this position.
The common peroneal nerve, a branch of the sciatic nerve, can be damaged from the
compression of the nerve between the head of the fibula and the frame of the leg
support. patients who sustain injury complain of a foot drop and the inability to extend the toes
in a dorsal direction or evert the foot.
Injury to the femoral or obturator nerves generally occurs during lower abdominalsurgical procedures with excessive retraction.
The obturator nerve also can be injured during a difficult forceps delivery or by
excessive flexion of the thigh to the groin.
A femoral neuropathy manifests with decreased flexion of the hip, decreased
extension of the knee, or a loss of sensation over the superior aspect of the thigh and
medial/anteromedial side of the leg.
An obturator neuropathy manifests with inability to adduct the leg with decreased
sensation over the medial side of the thigh.
Injury Recommendations for Prevention
Ulnar nerve (25%) Avoid excessive pressure on postcondylar groove of humerus
Keep hand and forearm either supinated or in neutral position
Brachial plexus (19%) Avoid the use of shoulder braces in patients in Trendelenburgposition (use nonsliding mattresses)
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Injury Recommendations for Prevention
Avoid excessive lateral rotation of head either in supine or prone
position
Limit abduction of the arm to <90 degrees in supine position
Avoid placement of high axillary roll in decubitus position — keep
roll out of axilla
Use ultrasound to find internal jugular vein for central line
placement
Spinal cord (16%) and
lumbosacral nerve root
(15%)
Be aware that the fraction of spinal cord injuries is increasing,
probably in relation to use of epidural catheters for pain
management
Follow current guidelines for regional anesthesia in anticoagulated
patients *
Sciatic and peroneal
(5%)Minimize time of surgery in lithotomy position
Use two assistants to coordinate simultaneous movement of both
legs to and from lithotomy position
Avoid excessive flexion of hips, extension of knees, or torsion of
lumbar spine
Avoid excessive pressure on peroneal nerve at the fibular head
Median (4%) and
radial (3%)
Be aware that 25% of injuries to the median and radial nerves were
associated with axillary block, and 25% of injuries were associatedwith traumatic insertion or infiltration of an intravenous line
Prevention of Perioperative Peripheral Neuropathies
Preoperative Assessment
When judged appropriate, it is helpful to ascertain that patients can comfortably tolerate
anticipated operative position
Upper Extremity Positioning
Arm abduction should be limited to 90 degrees in supine patients; patients who are positioned
prone may comfortably tolerate arm abduction >90 degrees
Arms should be positioned to decrease pressure on the postcondylar groove of the humerus
(ulnar groove). When arms are tucked at the side, a neutral forearm position is recommended.
When arms are abducted on armboards, either supination or a neutral forearm position is
acceptable
Prolonged pressure on radial nerve in spiral groove of humerus should be avoided
Extension of elbow beyond a comfortable range may stretch median nerve
Lower Extremity Positioning
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Lithotomy positions that stretch hamstring muscle group beyond a comfortable range may
stretch sciatic nerve
Prolonged pressure on peroneal nerve at fibular head should be avoided
Neither extension nor flexion of hip increases risk of femoral neuropathy
Protective Padding
Padded armboards may decrease risk of upper extremity neuropathy
Use of chest rolls in laterally positioned patients may decrease risk of upper extremity
neuropathies
Padding at elbow and at fibular head may decrease risk of upper and lower extremity
neuropathies
Equipment
Properly functioning automated blood pressure cuffs on upper arms do not affect risk of
upper extremity neuropathies
Shoulder braces in steep head-down positions may increase risk of brachial plexus
neuropathies
Postoperative Assessment
Simple postoperative assessment of extremity nerve function may lead to early recognition of
peripheral neuropathies
Documentation
Charting specific positioning actions during care of patients may result in improvements of
care by (1) helping practitioners focus attention on relevant aspects of patient positioning, and(2) providing information that continuous improvement processes can use to effect
refinements in patient care
Evaluation and Treatment of Perioperative Neuropathies
When a nerve injury becomes apparent postoperatively, it is essential to perform and
document a directed physical examination to correlate the extent of sensory or motor
deficits with the preoperative examination and any intraoperative events.
Whether or not an etiology is suspected, it is prudent to seek neurologic consultation
to define the neurogenic basis, localize the site of the lesion, and determine the
severity of injury for guiding prognostication.
With proper diagnosis and management, most injuries resolve; however, months to
years may be required.
For motor neuropathy, an electromyogram can be performed to determine the exactlocation of the injury. Abnormalities may point to the affected component within the
motor unit, which consists of the anterior horn cell, its axon and neuromuscular
junctions, and the muscle fibers that it innervates
An electromyogram may distinguish between radiculopathies, plexopathies, andneuropathies.
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Nerve conduction studies may be more useful to evaluate potential peripheral nerve
injuries, such as ulnar neuropathy.
Nerve conduction studies permit the assessment of motor and sensory nerves.
To evaluate motor integrity, the nerve is stimulated supramaximally at two points
along its course, and a recording is made of the electrical response of one of the
muscles that it innervates. The size of the muscle action potential provides an estimateof the number of motor axons and muscle fibers that are activated by the stimulus
For sensory conduction studies, the nerve fiber is stimulated supramaximally at one
point, and the sensory nerve action potential is recorded from another point. The
latency of the response can be interpreted as a reflection of the number of functioning
sensory axons.
Nerve conduction studies are useful for several reasons because they may reveal the
presence of a subclinical polyneuropathy that made the individual nerves more
susceptible to injury, and help distinguish between axon loss and demyelination,
which has significant implications regarding course and overall prognosis.
Most sensory neuropathies are generally transient and require only reassurance to thepatient with follow-up, whereas most motor neuropathies include demyelination of
peripheral fibers of a nerve trunk (neurapraxia) and generally take 4 to 6 weeks for
recovery.
Injury to the axon within an intact nerve sheath (axonotmesis) or complete nerve
disruption (neurotmesis) can cause severe pain and disability.
When reversible, recovery often takes 3 to 12 months. Interim physical therapy isrecommended to prevent contractures and muscle atrophy.
No single test can define the etiology of injury.
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Perioperative Eye Injury and Visual Loss
Although quite rare, perioperative eye injuries are a source of significant morbidity
and liability
Corneal abrasion is the most common type of perioperative eye injury and is
associated with direct trauma to the cornea from facemasks, surgical drapes, or other
foreign objects. Corneal abrasion also can be associated with decreased basal tear
production or swelling of the dependent eye in patients in the prone position. Patients
complain of pain associated with a foreign body sensation in the eye on awakening
from surgery. This injury also can occur from a dried section of cornea. Symptoms are
generally transient, and treatment comprises supportive care and antibiotic ointment
to prevent bacterial infection.Precautionary measures to reduce the incidence of
corneal abrasion include early and careful taping of the eyelids after induction of
anesthesia, care regarding dangling objects when leaning over patients, and closeobservation as patients awaken. Before they are completely awake, patients often try
to rub their eye or nose with pulse oximeter probes, armboards, and intravenous lines
attached, inadvertently endangering their eyes.
Postoperative visual loss is a devastating complication that has been associated with
specific surgeries and patient risk factors.
Speculated causes of significant permanent postoperative visual loss usually involvecompromise of oxygen delivery to elements of the visual pathway and include
ischemic optic neuropathy (anterior or posterior), retinal artery occlusion (central or
branch), and cortical blindness.
Ischemic optic neuropathy (ION) and central retinal arterial occlusion from direct
retinal pressure are the conditions most sited as potential causes. Perioperative factors associated with an increased risk of ION include prolonged
hypotension, long duration of surgery especially in the prone position, large blood
loss, large crystalloid use, anemia or hemodilution, and increased intraocular or
venous pressure from the prone position
Patient risk factors associated with ION include hypertension, diabetes,
atherosclerosis, morbid obesity, and tobacco use.