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Anaesthesiology
Patient Positioning and Potential Injuries
Built from Barash Clinical Anesthesia, 9th Edition
What’s inside
9 sections · 137 slides
Overview
- Scope of this topic
- Why positioning injuries still happen
- Key points of the chapter
- Documentation of positioning
General Principles
- Direct compression as a mechanism of injury
- Nerve stretch and ischaemia
- Point pressure and padding
- Perioperative inflammatory neuropathy
- Viral reactivation after surgery
- Mechanisms of positioning-related nerve injury
Supine Positions
- Circulatory effects of supine, head-down and head-up tilt
- Vascular gradients in the supine patient
- The horizontal supine position
- Limitations of the flat supine position
- The contoured (lawn chair) supine position
- Aortocaval compression and lateral displacement
- The lithotomy family of positions
- Standard lithotomy position
- Inguinal ligament stretch in lithotomy
- Leg holders and support devices
- Low lithotomy position
- High lithotomy position
- Risks of the high lithotomy position
- Exaggerated lithotomy position
- Complications of exaggerated lithotomy
Complications of Supine Positions
- Brachial plexus injury in closed claims
- Shoulder braces and plexus root injury
- Head displacement and plexus stretch
- Brachial plexus injury during median sternotomy
- Arm position during sternotomy: evidence
- Scapular winging from long thoracic nerve palsy
- Is long thoracic neuropathy positional?
- Axillary trauma from the humeral head
- Radial nerve compression
- Median nerve dysfunction
- Ulnar neuropathy: the commonest perioperative nerve injury
- Evidence that ulnar neuropathy is not purely positional
- Cubital tunnel retinaculum in flexion and extension
- Ulnar nerve subluxation at the elbow
- External compression without elbow flexion
- Anatomical reasons men are more affected
- Clinical features and detection of ulnar neuropathy
- Preoperative enquiry about ulnar symptoms
- Timing of symptom onset and its meaning
- Onset timing of postoperative ulnar symptoms
- Arm board and arm restraint complications
- Anterior interosseous nerve compression by a tight restraint
- Backache after supine positioning
- Hyperlordosis and paraplegia
- Compartment syndrome: what it is
- The compartment syndrome cycle
- Positional causes of compartment syndrome
- Clinical patterns of perioperative compartment syndrome
- Compartment syndrome outside lithotomy
Lateral Positions
- General principles of lateral positioning
- Evidence for the chest support in lateral position
- Standard lateral decubitus position
- Chest padding and shoulder protection
- Arm arrangement in the lateral position
- Stabilising the lateral patient
- Semisupine position and support of the elevated arm
- Preventing the torso from hanging on the arm
- Lateral jackknife position
- Physiological cost of the lateral jackknife
- Flexed lateral (kidney) position
- Safety measures in the kidney position
- Eye and ear injury in the lateral position
- Neck complications of the lateral position
- Suprascapular nerve stretch from shoulder circumduction
- Treatment and prevention of suprascapular neuropathy
Prone Positions
- The classic full prone position
- Perfusion gradients in the prone patient
- Consequences of the head lying below the heart
- Optic canal congestion in prone positioning
- Abdominal supports and frames for prone surgery
- Head support in the prone position
- Head rotation time limits when prone
- Preoperative assessment before prone positioning
- Eye protection in the prone position
- Conjunctival oedema when prone
- Perioperative visual loss after prone spine surgery
- Risk factors for ischaemic optic neuropathy in spine fusion
- Preoperative recommendations on visual loss
- Intraoperative management to reduce visual loss
- Positioning strategies to reduce optic canal congestion
- Neck injury in the prone position
- Head rotation and cerebral blood flow
- Sources of brachial plexus injury in the prone position
- Wrist restraint and contralateral plexus stretch
- Ulnar nerve compression by the pronated arm
- Thoracic outlet obstruction and prone arm placement
- Breast injury in the prone position
- Abdominal compression in the prone position
- Stoma and genital injury when prone
Head-Elevated Positions
- Conventional sitting position for neurosurgery
- Correct clamping of the head holder
- Supine position with head-up tilt
- Gradients created by modest head elevation
- Head-elevated semisupine position for shoulder surgery
- Lateral position with head elevated (park bench)
- Postural hypotension in head-elevated positions
- Venous air embolism: mechanism
- Detection and management of air embolism
- Macroglossia and airway oedema after neck flexion
- Uncertain mechanism of postoperative macroglossia
- Midcervical quadriplegia
- Sciatic nerve injury in seated patients
Head-Down Positions
- Robotic surgery and increased use of head-down tilt
- Head-down tilt and how the patient is retained
- Patient falls from steeply tilted tables
- Brachial plexopathy from head-down tilt
- Head-down tilt added to lithotomy
- Respiratory effects of head-down tilt
- Cranial effects of head-down tilt
- Shoulder braces in steep head-down tilt
- Limiting the use of steep head-down tilt
Summary and Takeaways
- Summary of the chapter
- Practical checklist for every position
- Position-specific hazards at a glance
- Highest-consequence complications
- References
- References (continued)
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- References (continued)
- Barash, Cullen, and Stoelting's Clinical Anesthesia, 9th Edition