Report on Patient Positioning for Anesthesia

Positioning for Anesthesia

1. PATIENT POSITIONING AND ASSOCIATED RISKS Presented by

2. PHYSIOLOGIC ASPECTS OF POSITIONING PHYSIOLOGIC RESPONSES Central Regional Local MAINTAIN HEMODYNAMICS Anesthesia Blunted

3. PHYSIOLOGIC ASPECTS OF POSITIONING PULMONARY PHYSIOLOGY ⬇️ FUNCTIONAL RESIDUAL CAPACITY ⬇️ ⬆️ V/Q MISMATCH HYPOXEMIA Anesthesia

4. GENERAL POSITIONING Cooperation = surgical team Patient well being and safety Surgical exposure Maintain spine and extremity neutrality Proper padding Secure patient into position

5. Supine Dorsal decubitus Head, neck, and spine are neutral position Arm abduction < 90 degrees Arms and forearms supinated or in neutral position with palms toward the body Padding

6. Supine variation : Lawn Chair Slight flexion of hips and knees Legs slightly above the heart

7. Supine variation : Frog Leg Hips and knees flexed and the hips are externally rotated Knees must be supported

8. Supine variation : Trendelenburg Patient in supine is tilted head down with the pubic symphysis as highest part of the trunk Increase venous return during hypotension Improve exposure during abdominal and laparoscopic surgery Prevent air emboli during central line placement

9. Supine variation : Trendelenburg Abdominal contents displaced toward diaphragm = dec FRC, dec pulmo compliance Can increase IOP and ICP Risk of aspiration Potential for postoperative upper airway obstruction Nonsliding mattresses, cautious use of shoulder braces

10. Supine variation : Reverse Trendelenburg Patient in supine is tilted upward so that the head is higher than any other part of the body Improve exposure during upper abdominal surgery Risk for hypotension

11. Supine : Complications Backache Extra padding : extensive kyphosis, scoliosis, history of back pain Obese patients : tipping over

12. Lithotomy Gynecologic, rectal, and urologic surgeries Legs abducted 30-45 degrees from the midline, the knees are flexed, and the legs held by supports Hips are flexed to varying degrees : standard, low, or high Legs raised or lowered simultaneously to prevent spine torsion Lower extremities padded

13. Lithotomy Transient increase in cardiac output Reducing lung compliance, potential decrease in tidal volume Normal lordotic curvature is lost Complication : lower extremity compartment syndrome

14. Lateral decubitus Patient lies on the nonoperative side Must be well secured Extremities : dependent leg somewhat flexed, pillow or padding placed between knees, dependent arm in front of the patient on a padded arm board, nondependent arm supported over folded bedding or suspended with an arm rest or foam cradle Arm abducted <90 degrees, use of axillary rolls

15. Lateral decubitus Head in neutral position Check : ears, eyes Pulmo physiology : V/Q mismatching

16. Prone Ventral decubitus Surgical access to posterior fossa of the skull, posterior spine, buttocks, perirectal area, lower extremities GA: establish ET intubation, IV access, Foley catheter and invasive hemodynamic access before turning patient Head maintained in neutral position using surgical pillow, horseshoe hadrest, or Mayfield rigid head pins

17. Prone Eyes and nose are free from pressure Legs padded and flexed slightly at the hips and knees Arms at patient’s sides, tucked in neutral position or placed on arm boards (with extra padding under the elbow) Abdomen hang freely Thorax supported by firm rolls or bolsters Pendulous structures should be clear of compression

18. Prone Pulmonary function superior to the supine position

19. Sitting Patient’s head and the operative field are located above the level of the heart Cervical spine and neurosurgical procedures Reduced blood loss Head : adequately fixed Arms : supported and padded Shoulders : even and sightly elevated Knees : slightly flexed Feet : supporte and padded

20. Sitting Risk : venous air embolism Rule out intracardiac shunts (contraindication) : TEE VAE complications : arrhythmias, acute pulmonary hypertension, and circulatory collapse Hypotension = compression stockings Pneumocephalus

21. Robotic Surgery : Steep Trendelenburg Supine tilted head down at 30 - 45 degrees and lithotomy with arms tucked in neutral position Nonslip mattress, chest straps in X configuration, shoulder braces (monitor for stretching at the neck) Perform test prior to docking robot Hemodynamic and respiratory changes Laryngeal edema and optic neuropathy

22. Pressure Injuries Stage I Stage II Stage III Stage IV

23. Bite Injuries

24. Peripheral nerve injuries Peripheral nerve injury is a complex phenomenon with a multifactorial cause. There is no direct evidence that positioning or padding alone can prevent perioperative neuropathies Compression injuries can manifest in several different ways. Neurapraxia is caused by a relatively short ischemia time and usually causes only a transient dysfunction. Axonotmesis is a demyelinating injury. Neurotmesis is due to a severed or disrupted nerve and usually deficits are permanent.

25. Prevention of Peripheral Nerve Injuries Preoperative history and physical assessment Patient can tolerate position Body habitus, preexisting neurologic symptoms, diabetes mellitus, peripheral vascular disease, alcohol dependency, arthritis, and gender Upper Extremities Abduction </= 90 degrees in supine Arms on arm board : supination or neutral forearm position Arms tucked at side : neutral forearm position Lower Extremities Stretching of hamstring muscle group within comfortable Range Limiting hip flexion

26. Prevention of Peripheral Nerve Injuries Protective Padding Padded arm boards Chest rolls Padding at the elbow Padding to protect fibular nerve Complications : tight padding = injury Equipment Postoperative Assessment Documentation

27. Evaluation and Treatment of Perioperative Neuropathies Correlate and document the extent of sensory or motor deficits with the preoperative exam as well as any intraoperative events Neurologic consultation Proper diagnosis and management = most injuries resolve Sensory neuropathies = mostly transient Motor neuropathies = 4-6 weeks recovery; interim PT Electrophysiologic evaluation after 4 weeks = more definitive info

28. Perioperative Eye Injury and Visual Loss Corneal abrasions are most common GA: no lid reflex, decreased tear production FB sensation, photophobia, blurry vision, erythema Risk factors : increased age, long surgery, prone and Trendelenburg position, supplemental oxygen

29. Perioperative Eye Injury and Visual Loss Early and careful taping of the eyelids, care with dangling objects, close observation Ophthalmic ointments Postoperative vision loss (POVL) = ischemic optic neuropathy and central retinal artery occlusion

30. Anesthesia outside the Operating Room GI endoscopy Cardiac catheterization Interventional radiology Neuroradiology MRI / CT tomography Office-based procedures

31. In summary…

32. Positioning of patients = essential aspect of intraoperative care Operative team works together when positioning to ensure patient safety and comfort in addition to desired surgical exposure Final position should appear natural

33. Thank you!