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The importance of correct patient positioning in theatres and implications of mal-positioning.

Patient positioning in theatre pertains to how a patient is transferred and positioned for a specific procedure. A number of different positions can be adopted depending on the exposure required for the procedure, but must ensure the comfort and safety of the patient at all times. Careful planning must consider not only the procedure itself, but also the type of anaesthesia or sedation that needs to be administered, the duration of the procedure and any co-morbidities the patient may have. The importance of patient positioning can often be overlooked and underestimated, despite the evidence that proper patient positioning can prevent immediate problems and reduce the risk of long-term pain and disability (Warner 2004). In this article, we discuss the importance of correct patient positioning and associated problems, look at common positions adopted in theatre and highlight important considerations.

Why patient positioning is important

Patient safety is a central focus of care within the NHS framework (Carruthers & Philip 2006) and every healthcare practitioner must ensure that patients are protected from harm where possible. Proper positioning reduces the risk of pressure-related damage to nerves, muscle, skin, and joints. The anaesthetised or sedated patient is unable to communicate if they have been placed in a compromising or dangerous position, hence a proactive approach should be taken to prevent the deleterious effects of patient mal-positioning.

Correct positioning of a patient allows optimum exposure of the operative field (Millsaps 2006). Positioning must also take into account the degree of movement that may be necessary during the procedure, for example knee and shoulder arthroscopy require significant movement of the lower and upper limbs respectively during the procedure and the surgical field must be setup accordingly. Additional equipment e.g. fluoroscopy, may also be required during the procedure and the method by which it will access the operative site whilst maintaining a sterile field should be planned for. The effects of patient transfer and positioning on any equipment attached to the patient such as intravenous access lines and catheters must be catered for. The anaesthetic requirement for maintaining the respiratory and circulatory function of the patient must also be considered.

Poorly executed patient transfer and positioning may also negatively impact on the health of theatre staff and be costly to the affected individual both in terms of suffering and time off work. Videman et al (1985) have shown that back injuries may be prevented by teaching correct patient-handling skills. It may be necessary to provide hoisting equipment with special beds for the lifting and transfer of the morbidly obese patient to prevent injuries to the healthcare worker (Kaffarnik & Utzolino 2009).

Problems with poor patient positioning

Complications with patient positioning can occur in transit when moving the patient into and out of theatre, or during the procedure itself. Problems may arise when the patient is poorly placed for a prolonged period of time. Four of the most common complications are discussed below.

1. Skin pressure sores: Skin pressure sores can result in sepsis which may be fatal. Stevens et al (2004) have shown that 'patients with longer operative times were at greater risk of skin breakdown and required greater care during preoperative positioning'. Theatre staff should ensure that pressure points around bony prominences such as the iliac crest, sacrum and heels, are well padded with pillows, ankle pads etc. and if necessary, the patient moved slightly in lengthy procedures. Theatre staff should also be proactive in checking for signs of skin breakdown such as redness or bruising after the procedure. This allows appropriate measures to be taken to avoid pressure sores developing. The right equipment to prevent damage, for example soft pads, pillows, axillary or chest rolls should be used. Ideally they should 'absorb compressive force, redistribute pressure, prevent excessive stretching and provide support for optimum stability' (Rothrock 2003).

2. Nerve compression: Theatre staff must be aware of the potential risk of nerve injury in a poorly positioned patient. Parks (1973) reviewed 50,000 surgical procedures and reported 0.14% of cases were linked with peripheral nerve complications. Rothrock (2003) noted that it only takes minutes for neurological complications to arise, but they have long-lasting effects on the patient.

Ulnar nerve palsy arises from compression of the ulnar nerve. The injury may result in a 'claw hand' deformity and the inability of the fingers of that hand to abduct and adduct, as well as a loss of sensation to the medial aspect of the hand. This can occur when the patient's arm slips off the mattress unnoticed by the theatre staff and the ulnar nerve becomes compressed by the medial epicondyle at the elbow and the table (Millsaps 2006). Brachial plexus injuries can occur in either the prone or supine position where the head is rotated and laterally flexed, or the arm is extended posteriorly. The complications that arise depend on which nerves in the plexus are damaged. Radial nerve damage will result in a wrist drop, whereas median nerve damage may result in an 'ape hand' deformity with a loss of the ability to grasp with that hand (Winfree & Kline 2005). Common peroneal nerve damage results in a foot drop and a loss of sensation over the lateral leg and dorsum of the foot (Winfree & Kline 2005).

3. Deep vein thrombosis: Improving patient safety is an important priority for the National Health Service. Patient safety initiatives aimed at creating a safe operating theatre culture are increasingly being adopted and reliable means of measuring their impact are being developed (Pronovost et al 2005, Makary et al 2006), and these include rates of deep vein thrombosis (DVT).

DVT can result from prolonged periods of immobility causing blood stasis, and is associated with the potential life threatening complication of pulmonary embolic phenomenon. They can arise particularly in long procedures where the patient has suffered fluid loss. Prophylactic anti-embolism stockings should be worn and consideration given to the use of external pneumatic compression applied to the lower legs. Early mobilisation of the patient in the postoperative period and prophylaxis with low molecular weight heparin should be encouraged unless contraindicated (NICE 2007, Pearse et al 2007).

4. Compartment syndrome: This is a life-and limb-threatening complication associated with patient mal-positioning and has been covered in detail in an earlier article by the authors (Malik et al 2009). Prolonged compression of the vessels of a limb may impede circulation to the appendage and cause a compartment syndrome resulting in muscle necrosis and loss of function. Roher et al (2008) noted that 'Long-lasting operations in the lithotomy position are accompanied by the risk of an acute compartment syndrome of the lower extremities'. Safe positioning must allow for adequate blood flow to all four limbs.

Different patient positions used in surgical practice

Millsaps (2006) describes the four most common surgical positions as supine, prone, lateral and the lithotomy position and these are discussed below. The choice is based primarily on the procedure to be carried out, for example the prone position allows access to the spine for epidurals and spinal surgery whereas the lithotomy position is used in gynaecological procedures to permit access and clear visualisation of the internal and external female genitalia.

1. Prone position: The patient is placed lying flat face down on the operating table with arms placed either on the side of the body or forward with the elbows flexed and palms down. The face is either facing down into a specially designed headrest or turned to the side. The patient is generally anaesthetised in the supine position and moved into the prone position by a safe log roll. Movements of the spine should be minimised. A minimum of six theatre staff, including the anaesthetist, should be employed in the safe log-rolling of the patient. When placing patients in this position, it is important to support the head and neck and this is usually done by the anaesthetist. It is also important to have sufficient staff to support the patient along the length of their body whilst performing the log roll. If the arms are to be brought forwards, both arms should be moved into position at the same time, and similarly returned to the side simultaneously at the end of the operation.

Potential risks are brachial plexus injury if the head is rotated and laterally flexed or the arms hyper-extended during the transfer. Shoulder dislocations and other arm injuries have also been reported in the literature (Edgecombe et al 2008). There are well documented adverse physiological effects to the respiratory and cardiovascular system in the prone position. Primarily these are the domain of the anaesthetist who should be well trained in optimising the patient and reducing the risk of these occurring. An increased risk of ophthalmic injury is well established in patients operated in a prone position (Lee 2003). The mechanism of injury is believed to be central retinal artery occlusion and ischaemic optic neuropathy (Kamming & Clark 2005).

Theatre staff should be aware of the existence of and correct use of aids to optimise the prone patient positioning. These include the Montreal mattress where a central hollow helps prevent abdominal compression and improves ventilation and venous return (Schonauer et al 2004), and the horse shoe head-rest that allows ventilation without compromise of the intubation equipment. Theatre staff should be aware of parts of the body at risk from pressure effects. Excessive compression of the breast and male genitalia must be prevented by adequate padding.

2. Supine position: The patient is placed lying flat on their back, face up on the operating table with arms placed either on the side of the body or with the elbows flexed and palms on the chest. Transfer of the patient from the anesthetic table to the operating table is undertaken in a smooth coordinated manner. A minimum of four people including the anaesthetist are recommended (Charney 2003). Ulnar nerve injury resulting from pressure of the elbow at the edge of the operating table should be prevented by ensuring that the arm does not slip off the operating table and that there is soft padding around the elbow. Excessive external pressure on the humerus that could lead to radial nerve injury should also be avoided. Soft support on the lumbosacral area of the back will prevent backache. Soft padding over the sacrum and a pillow under the occiput prevents the development of pressure sores. Intraoperatively, theatre staff should not 'prop themselves up' on the patient as this can lead to pressure sores, reduced ventilation and reduced venous return. Pressure on the calf muscle can increase the risk of DVT and should be reduced by wearing thrombo-embolic deterrent (TED) stockings and pneumatic compression devices.

3. Lithotomy position: The patient is laid supine and the distal end of the bed detached so that the legs can be elevated in stirrups. The medical history of the patient should be considered before placing the patient in the lithotomy position and any restrictions to hip, knee or ankle movements noted. It may be necessary to modify the lithotomy position taking these factors into account. Both legs should be moved slowly and simultaneously by two people when positioning the patient in and out of the stirrups to avoid excessive shear and torsional stresses at the hip joint and pelvis.

Nerve injuries following the lithotomy position are well documented. Concomitant hip flexion should be used when placing anesthetised patients in a lithotomy position where the lower limbs are abducted to greater than 30[degrees] to decrease the risk of obturator nerve injury (Litwiller et al 2004). Stretching injures to the sciatic nerve should also be prevented by avoiding excessive external rotation of the hip with the knee in extension. Common peroneal nerve injuries resulting in foot drop and loss of sensation over the dorsum of the foot have been reported in the literature (Warner et al 1994) and should be avoided by correct placement of the legs in the stirrups.

Lower limb acute compartment syndrome after prolonged urological, colorectal, and gynaecological procedures are also well-documented. Simms & Terry (2005) estimate that 1 in 500 cystectomy procedures may result in a compartment syndrome. Theatre staff should communicate with ward staff postoperatively to ensure that regular lower limb neurovascular assessments are made in patients placed in the lithotomy position for a prolonged period of time.

4. Lateral or decubitus position: The patient is positioned on their lateral side with their arms parallel to each other. The most important aspect is to maintain body alignment and stability. The neck is kept in a neutral position, and the body stabilised with positional devices to prevent the patient moving freely on the table. The patient is typically anaesthetised in the supine position, and then moved into the lateral position. Peroneal nerve injury may arise from pressure on the lateral aspect of the knee due to the weight of the other leg and could be reduced by appropriately placed padding under the lower knee.

Padding between the knees should also be used to protect against pressure sores over medial condyles. Brachial plexus injuries are prevented by placing an axillary roll underneath the bottom arm. The general principles of avoiding skin necrosis and DVT apply.

How to prevent patient malpositioning

Prior to the patient arriving in the anaesthetic room, theatre staff should ensure that the correct operating table and all necessary attachments are available and in good working condition. Sufficient personnel should be available to allow safe and controlled transfer of the patient. Following discussion with the anaesthetist and the medical or surgical practitioner, theatre staff should decide on the appropriate mode of patient transfer and positioning.

The patient must be free to move and all limbs controlled during transfer. Any attachments to the patient such as monitoring devices, catheters, intravenous access etc must be secured or temporarily removed. The patient should be transferred in a coordinated manner that is directed by the anaesthetist. Hyperextension of the extremities should be avoided at all costs (Edgecombe et al 2008). Easyslide, patslide, or roll boards may all be used in transferring the patient. Their basic principle involves gently rolling the patient slightly to one side and placing the device under them, then rolling the patient back to a supine position and sliding them onto the operating table. Finally the patient is gently rolled the other way and the device removed.

Once transferred and positioned the patient should be secured appropriately. Restraints must be secure but not excessively tight. Placing restraints over superficial nerves or bony prominences should be avoided. The position of the patient must not compromise the use and visualisation of monitoring equipment for the theatre staff as this could put the patient at risk.

Patient factors are also important in adverse outcomes in poorly positioned patients and must be addressed to minimise the risk of injury. Special care should be taken in obese individuals who face a greater likelihood of nerve and other pressure point injury (Meltzer 2001). The elderly population has also been observed to be more susceptible to pressure point injury due to their generally poorer peripheral circulation, friable skin and reduced capacity to tolerate circulatory compromise.

An algorithm to ensure correct patient positioning devised by the Association of Operating Room Nurses (2005) and is outlined below

* Plan for the procedure in advance.

* Identify the position that will be used and ensure that any equipment necessary for the safe transfer and positioning of the patient is available and in working order.

* A dedicated theatre member should coordinate the safe transfer and positioning of the patient.

* Ensure adequate theatre staff numbers and communicate the responsibility of each theatre member involved in the process of transfer and positioning.

* Consider repositioning the patient in long procedures to reduce the risk of pressure sores, DVT formation and compartment syndrome.

* Check the patient before and after the procedure for tell-tale signs of complications from the positioning. Ask the patient once awake if they have any unexpected pain or numbness.

* Consider preoperative and postoperative nerve conduction studies for patients at risk such as prolonged immobilisation in the prone position.

Conclusion

Every healthcare practitioner must ensure that patients are protected from harm where possible and correct patient positioning in theatre is crucial to avoid the preventable complications of pressure sores, nerve compressions, DVTs and compartment syndrome. It is important to plan for patient transfer and positioning in a safe and coordinated manner, and to use all aids and appliances available to prevent complications. It is also important to check the patient before and after the procedure for tell-tale signs of complications from the positioning.

Provenance and Peer review: Commissioned by the Editor; Peer reviewed; Accepted for publication December 2009.

References

Association of Operating Room Nurses 2005 Recommended practices for positioning the patient in the perioperative practice setting In: Standards, Recommended Practices, and Guidelines Denver, CO, AORN Journal

Carruthers I, Philip P 2006 Safety First: a report for patients, clinicians and healthcare managers London, UK, Department of Health Publications

Charney W 2003 Preventing back injury to healthcare workers using lift teams: Data from 18 hospitals Journal of Health and Safety 1 21-29

Edgecombe H, Carter K, Yarrow S 2008 Anaesthesia in the prone position British Journal of Anaesthesia 100 165-183

Kaffarnik M, Utzolino S 2009 Postoperative management of patients with BMI > 40 kg / m2 Zentralblatt fur Chirurgie 134 43-49

Kamming D, Clarke S 2005 Postoperative visual loss following prone spinal surgery British Journal of Anaesthesia 95 257-260

Lee LA 2003 Postoperative visual loss registry: preliminary analysis of factors associated with spine operations American Society of Anesthesiology Newsletter 67 7-8

Litwiller JP, Wells RE, Halliwill JR, Carmichael SW, Warner MA 2004 Effect of lithotomy positions on strain of the obturator and lateral femoral cutaneous nerves Clinical Anatomy 17 45-49

Makary MA, Sexton JB, Freischlag JA et al 2006 Patient safety in surgery Annals of Surgery 243 628-635

Malik AA, Khan WS, Chaudhry A, Ihsan M, Cullen NP 2009 Acute compartment syndrome- a life and limb threatening surgical emergency Journal of Perioperative Practice 19 137-142

Malone PC, Agutter PS 2006 The aetiology of deep venous thrombosis Q J Med 99 581-593

Meltzer B 2001 A guide to patient positioning Available from: www.outpatientsurgery.net/2001/os04/f5.shtml [Accessed October 2009]

Millsaps CC 2006 Pay attention to patient positioning! RN Magazine 69 (1) 59-63

National Institute for Health and Clinical Excellence 2007 Venous Thromboembolism London, UK, Department of Health Publications

Parks BJ 1973 Postoperative peripheral neuropathies Surgery 74 348-357

Pearse EO, Caldwell BF, Lockwood RJ, Hollard J 2007 Early mobilisation after conventional knee replacement may reduce the risk of postoperative venous thromboembolism Journal of Bone & Joint Surgery 89B 316-322.

Pronovost PJ, Weast B, Rosenstein B et al 2005 Implementing and validating a comprehensive unit-based safety program Journal of Patient Safety 1 33-40

Roher H, Onmann C, Beck L 2008 Acute compartment syndrome due to positioning during long-lasting gynecological operations in the lithotomy position Gynakologe 41 1023-1026

Rothrock J C 2003 Alexander's Care of the Patient in Surgery (12th edition) St. Louis, MO, Mosby

Schonauer C, Bocchetti A, Barbagallo G, Albanese V, Moraci A 2004 Positioning on surgical table European Spine Journal 13 S50-S55

Simms MS, Terry TR 2005 Well leg compartment syndrome after pelvic and perineal surgery in the lithotomy position Postgraduate Medical Journal 81 534-536

Stevens J, Nichelson E, Linehan W 2004 Risk factors for skin breakdown after renal and adrenal surgery Urology 64 246-249

Videman T, Rauhala H, Asp S et al 1989 Patient-handling skill, back injuries, and back pain. An intervention study in nursing Spine 14 148-156

Warner M, Martin J, Schroeder D, Offord KP, Chute CG 1994 Lower-extremity motor neuropathy associated with surgery performed on patients in a lithotomy position Anesthesiology 81 6-12

Warner M 2004 Patient Positioning Strategies Available from: www.outpatientsurgery.net/2003/os08/patient_positi oning_strategies.php [Accessed October 2009]

Winfree CJ, Kline DG 2005 Intraoperative positioning nerve injuries Surgical Neurology 63 5-18

Rimi Adedeji

BSc

Medical Student, Imperial College, London

Emeka L Oragui

BA Neurosceince (Cantab), MBBS (London), MRCS (Eng)

Specialist Trainee Registrar Surgery, Department of Trauma and Orthopaedics, West Middlesex University Hospital, London

Wasim Khan

MBChB, MSc, MRCS, PhD

Academic Clinical Fellow, ULL Institute of Orthopaedic & Musculoskeletal Sciences, Royal National Orthopaedic Hospital, London

Nimalan Maruthainar

FRCSEd (Tr & Orth)

Department of Orthopaedics, Royal Free Hampstead NHS Trust, London

Task 1

Explore your department and identify the equipment necessary for the safe transfer and positioning of the patient in the prone position.

Notional Learning Hours 1 hour

Knowledge and Skills Dimension

Core 3: Health, Safety and Security

HWB9: Equipment & devices to meet health and well-being needs

G1: Learning and development

Task 2

Virchow described his triad explaining that clotting within a blood vessel occurs for three reasons. Review Virchow's triad (Malone & Agutter 2006) and discuss how these three factors can be influenced in theatre to reduce the chances of developing a DVT?

Notional Learning Hours 1 hour

Knowledge and Skills Dimension

HWB6: Assessment and treatment planning

HWB7: Interventions and treatment

HWB9: Equipment & devices to meet health and well-being needs

G1: Learning and development

Task 3

Compartment syndrome is a life and limb threatening complication of patient mal-position. Read the article:

Malik et al 2009 Acute compartment syndrome--a life and limb threatening surgical emergency Journal of Perioperative Practice 19 (5) 137-142

Notional Learning Hours 1 hour

Knowledge and Skills Dimension

HWB6: Assessment and treatment planning

HWB7: Interventions and treatment

HWB9: Equipment & devices to meet health and well-being needs

G1: Learning and development

Task 4

What happens when a routine elective procedure that was meant to last one hour lasts longer than two hours? What should happen?

Notional Learning Hours 30 mins

Knowledge and Skills Dimension

Core 3: Health, Safety and Security

Core 4: Service improvement

Core 5: Quality

HWB2: Assessment and care planning to meet people's health and well-being needs

HWB7: Interventions and treatment

Task 5

A seventy-year-old patient undergoes an elective total hip replacement under general anaesthetic and is placed in a lateral position. After the procedure, in recovery, the patient complains of an inability to lift his foot up and a loss of sensation over the lateral leg and dorsum of the foot. What could have happened and what will you do?

Notional Learning Hours 30 mins

Knowledge and Skills Dimension

Core 2: Personal and people development

Core 3: Health, Safety and Security

HWB6: Assessment and treatment planning

HWB7: Interventions and treatment

Additional Learning Resources

Associated AfPP on line modules:

* Patient Assessment in Recovery

* Circulation and Invasive Monitoring

* The Multi-disciplinary Team in the Operating Theatre

* Communication Skills

* Patient Care in the Operating Department

* Liability and Accountability

* Care and Responsibility

Web links and key documents

Malik AA, Khan WSA, Chaudhry A, Ihsan M, Cullen NP 2009 Acute compartment syndrome--a life and limb threatening surgical emergency Journal of Perioperative Practice 19 (5) 137-142 Malone PC, Agutter PS 2006 The aetiology of deep venous thrombosis Q J Med 99 581-593

No competing interests declared

Members can search all issues of the BJPN/JPP published since 1998 and download articles free of charge at www.afpp.org.uk.

Access is also available to non-members who pay a small fee for each article download.

Correspondence address: Mr W Khan, Department of Trauma & Orthopaedics, Royal Free Hospital, London, NW3 2QG, UK. Email: wasimkhan@doctors.org.uk
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Title Annotation:OPEN LEARNING ZONE
Author:Adedeji, Rimi; Oragui, Emeka; Khan, Wasim; Maruthainar, Nimalan
Publication:Journal of Perioperative Practice
Article Type:Report
Geographic Code:1USA
Date:Apr 1, 2010
Words:3860
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