1. Surgical Patient Positioning ST210 Concorde Career College, Portland

2. Positioning Objectives:  List the basic surgical positions and analyze the use of each  Identify basic positioning aids and describe the use of each

3. Positioning Objectives:  List the steps for placing the patient in the basic surgical positions and list the potential hazards and safety precautions that relate to each position

4. Surgical Technology Lecture Series 2000© Power-Point®

5. Production Notes Primary Author - Kevin Frey CST, MA Coauthor and Executive Editor - Bob Caruthers CST, PhD Series Editor - Teri Junge, MEd, CSFA, CST, FAST

6. Table of Contents  General Information  Patient Safety  Equipment  Patient Positions

7. General Information

8. Position Determination  General factors  Surgical procedure  Surgeon’s preference  Technique of anesthetic administration  Patient factors  Age  Size (height and weight)  Cardiopulmonary status  Preexisting conditions

9. Responsibilities  Choice of position is made by surgeon and anesthetist  The responsibility for ensuring the patient is properly positioned belongs to the surgeon

10. Timing of Positioning  Patient is not positioned or moved until the anesthetist indicates it is okay to do so  Factors that influence time of positioning  Site of surgical procedure  Age and size of patient  Type of anesthetic administered  Pain associated with moving conscious patient

11. Patient Safety

12. Safety  Properly identify patient  Operating table and gurney locked  Mattress secured to operating table  Minimum of 2 people assist an awake patient during transfer  Person on “gurney side” helps patient move to operating table  Person on “operating table side” prevents patient from falling off the narrow table

13. Safety (continued)  Minimum 4 persons to move unconsciousness, obese, or weak patients  Move on the count of three  Anesthetist controls timing  Anesthetist controls head and neck at all times  Lift - do not slide or pull the patient  Surgeon is responsible for stabilizing un-splinted fractures during move

14. Safety (continued)  Anesthetized patient is moved slowly to allow circulatory system to adjust  Body parts not to extend beyond table edges, rest on metal parts, or unpadded surfaces  Body exposure kept to minimum  Prevent hypothermia  Maintain patient’s dignity (especially awake patient)

15. Safety (continued)  Protect arms  Prevent accidental IV removal  Avoid hyperextension of arm board  Be sure patient in the supine position has not crossed legs  Uncrossed to avoid neurovascular compromise

16. Safety (continued)  Chest rolls are used in the prone position to facilitate respiration  Protect patient’s fingers and skin at flex points of table  Mayo stand must not rest on patient  If table raised during procedure; Mayo stand must also be raised

17. Respiratory System Requirements  Unhindered diaphragmatic movement  Patent airway  Prevent hypoxia  Some hypoxia may be unavoidable  Facilitate inhalation anesthesia  No constriction about neck or chest  Place arms at sides, on arm boards, not crossed on the chest

18. Circulatory System Requirements  Adequate circulation required  Maintain BP  Provide oxygenated blood to tissue  Facilitate venous return,  Prevent thrombus formation  Pressure on peripheral blood vessels avoided  Body support and safety straps not too tight

19. Peripheral Nervous System Requirements  Avoid prolonged pressure or stretching on peripheral nerves  Injury can range from sensory and motor loss to paralysis  Positioning devices that come in contact with patient must be well padded

20. Peripheral Nerves (continued)  Frequent sites of injury  Divisions of the brachial plexus  Due to extreme positions of head and arm  Ulnar nerve  Radial nerve  Peroneal nerve  Extremity nerves damaged by compression against bone, stirrups, or operating table  Facial nerve

21. Musculoskeletal System Requirements  Anesthetized patients lack muscle tone or control  Strain on muscles results in injury  Body alignment must be maintained

22. Soft Tissue Requirements  Body weight distributed unevenly on operating table  Weight on bony prominences can lead to skin ulceration  Tissue folded under skin of obese patient will not receive proper perfusion  Debilitated patients and diabetics are at high risk for decubitus ulcers  Wrinkled sheets and edges of positioning devices under the patient can cause pressure on skin

23. Patient Access  Anesthetist must be able to  Attach monitoring devices  Administer anesthesia  Observe patient  Maintain access to airway and IV sites

24. Equipment

25. Operating Table  Electric or manual hydraulic  Metal top  3 hinged sections: head, body, leg  Allow patient to be manipulated; flexed  Joints of table referred to as breaks  Flexing the table is referred to as breaking

26. Operating Table (continued)  Metal crossbar between two upper sections to elevate kidney area  X-ray penetrable top extends length of table for insertion of X-ray cassette  Rubber; foam mattress adhered with Velcro®  Foot extension board for tall patient; also used with lithotomy position

27. Operating Table (continued)  Table is manipulated into desired position either by electronic controls or lever-operated hydraulic system  Control set on back, side, foot, or flex  Brake is set to maintain table position

28. Table Accessories  Safety belt (knee strap)  Placed over thighs 2” above knees  Circulator should be able to pass fingers between strap and patient  Some straps attached at sides of table; others fastened in middle  Blanket placed on patient between skin and belt  Belt placed over, not under blanket

29. Table Accessories (continued)  Anesthesia screen  Metal bar attaches to head of table to hold drapes off patient’s face  Substitute for IV poles  Lift sheet (draw sheet)  Folded sheet placed horizontally across top of sheet on operating table  Can be used in moving patient

30. Table Accessories (continued)  Lift sheet (continued)  Arms can be enclosed in sheet with hands placed palm down or turned inwards toward body  Finger tips must extend beyond edges of sheet  Tuck sheet under patient’s sides  Do not tuck under sides of mattress

31. Table Accessories (continued)  Arm boards  Support arms  Provide access to IV  Support arm or hand where surgical site is located  Hand placed palm up on board to prevent ulnar nerve pressure and abnormal shoulder rotation Exceptions  Prone position  Upper arm of lateral position

32. Table Accessories (continued)  Arm boards (continued)  Arm board can be adjusted to different angles  Never abduct arm more than 90 degrees from shoulder  Double arm board  Arms positioned one above the other  Also called overhead arm support

33. Table Accessories (continued)  Wrist straps  Narrow straps placed around wrists to secure hand and arm to arm board  Hand table (upper extremity table)  Slipped under mattress on one side of table  Other end of table supported by legs  Can use 2 arm boards placed side-by-side; not as effective or safe

34. Table Accessories (continued)  Shoulder braces  Padded concave supports to prevent patient from slipping off table when using Trendelenburg position  Acromion processes must rest on braces, not muscles or soft tissue near the neck

35. Table Accessories (continued)  Kidney rests  Padded concave pieces that slide under mattress on kidney elevator  Placed snugly against body to provide stability in kidney position

36. Table Accessories (continued)  Body (hip) restraint strap  A wide belt or tape (preferred) is used  Placed over patient’s hips to help secure patient in lateral position

37. Table Accessories (continued)  Hemorrhoid strap  Benzoin spray  3” wide adhesive tape  Strips placed approximately 4” lateral to surgical site  Use 2 strips per side  Spread buttocks when patient is in Kraske position

38. Table Accessories (continued)  Stirrups (candy canes)  Metal poles placed in holder on each side of operating table to support legs and feet in lithotomy position  Feet supported by canvas or fabric loops, suspending the legs

39. Table Accessories (continued)  Metal footboard  Foot extension board placed perpendicular to table to keep patient from slipping off operating table in reverse Trendelenburg  Used to prevent foot drop during extended procedures

40. Table Accessories (continued)  Donut  Ring-shaped foam pad for head  Also used to protect pressure points  Bolsters  Used to elevate specific part of body  Chest roll  Axillary roll

41. Table Accessories (continued)  Suction bean bag  Placed on top of operating table  Patient lays on the bean bag  Suction attached to one end of bag  As air is withdrawn the pad hardens and is molded to the patient’s body by the surgical team

42. Table Accessories (continued)  Suction bean bag (continued)  Suction disconnected to release  To allow air to reenter, valve is squeezed  Excellent positioning device for stabilizing patient in lateral position

43. Patient Positions

44. Supine (Dorsal) Position  Patient lies on back  If arms at side, supported by draw sheet, palms down  If arms on arm boards, palms up  Legs straight and in line with head and spine  Hips parallel to spine

45. Supine (continued)  Safety belt across thighs 2” above knees  Pillows placed under head, under knees, under lumbar curvature  Protect heels from pressure  Feet must not be in prolonged plantar flexion (foot drop)

46. Supine (continued)  Procedures  Anterior surface of body  Extremities  Modifications  Procedures on face or neck: Place rolled towel lengthwise along upper boarder of scapula to slightly hyperextend neck and/or lower head section of operating table

47. Supine (continued)  Modifications (continued)  Modified dorsal recumbent (frog leg)  Knees slightly flexed with a pillow under each  Thighs externally rotated  Soles of feet rest on table top

48. Trendelenburg Position  Supine with head tilted downward  Safety belt 2” above knees  Shoulder brace may be used  Lung volume decreased  Heart mechanically compressed by pressure of organs against diaphragm

49. Trendelenburg (continued)  Level entire table slowly at end of procedure  Procedures  Lower abdomen or pelvis to allow abdominal viscera to fall away from surgical site

50. Reverse Trendelenburg Position  Supine with head tilted upward  Padded foot board may be necessary  Small pillows placed under knees and lumbar curvature  Donut for the head  Safety belt 2” below the knees  Footboard may be used to retain patient on table

51. Reverse Trendelenburg (continued)  Procedures  Upper abdomen  Allows abdominal viscera to fall away from surgical site  Examples: gallbladder, biliary tract, splenectomy  Thyroidectomy  Facilitates breathing and decreases blood supply to surgical site

52. Fowler’s (Sitting) Position  Start with patient in the supine position  Buttocks at flex in table  Knees over lower break  Foot section lowered slightly to flex knees  Body section raised becoming the “back” of the chair  Arms rest on armboards parallel to operating table  Alternative: Secure arms to large pillow placed on lap

53. Fowler’s (continued)  Safety belt placed 2” above the knees  Table tilted slightly head downward  Table resembles modified armchair  Procedures  Shoulder  Nasopharyngeal  Facial  Breast reconstruction

54. Lithotomy Position  Wrap ankle and foot of patient with towel, leggings, or cotton boots for padding against canvas loops  Transfer head section to foot end of table to serve as foot extension  Place stirrup on side of table that will not be used for patient transfer

55. Lithotomy (continued)  Start with the patient in the supine position  Arms placed on armboards  Hands not to extend along table where fingers could be crushed in breaks while leg section is lowered or raised  Buttocks resting along break between body and leg section  Place other stirrup  Stirrups must be of equal position and at an appropriate height according to length of patient’s legs

56. Lithotomy (continued)  When anesthetist gives permission, both legs are raised simultaneously by two persons  Support the foot, ankle, and calf  Flex the knees and legs; place inside the stirrup posts  Place feet in canvas loops  First loop of canvas around ankle  Second loop around sole of foot

57. Lithotomy (continued)  Lower section of mattress is removed  Leg section of table is lowered  Lower leg or ankles must not touch any metal part of the stirrup  Buttocks must be even and not extend beyond table edge  Extension beyond edge causes strain on lumbosacral muscles and ligaments due to body weight placed on sacrum

58. Lithotomy (continued)  Conclusion of surgical procedure  Raise leg section  Replace mattress  When anesthetist gives permission, both legs are extended, brought together, and lowered slowly and simultaneously by two persons  Prevents hypotension as blood reenters legs and leaves the torso  Essential to avoid lower back strain  Reapply safety belt  Safety belt not applied when patient is in lithotomy

59. Lithotomy (continued)  Lung compliance is decreased by pressure of thighs on abdomen  Diaphragmatic movement restricted  Procedures  Perineal  Vaginal  Urological  Rectal

60. Prone Position  Patient lays on abdomen (face down)  Chest rolls pre-placed on operating table  Extend from clavicles to iliac crest to facilitate respiration  Patient is anesthetized and intubated in the supine position on the gurney  When anesthetist gives permission, patient is slowly rolled onto abdomen on operating table by team of at least 4 people

61. Prone (continued)  Breasts moved laterally  External genitalia toward foot of table  Arms  Placed along side of body with palms up or towards side of body  Can cause pressure on breasts  Placed on armboards, angled with elbows flexed  Palm downward  When moving arm, lower toward floor rotating in an upward in natural movement

62. Prone (continued)  Head turned to one side; use a donut  Pillow under anterior of ankles  Safety belt above the knees  Procedures  Spine  Posterior aspect of lower extremity

63. Kraske (Jackknife) Position  Modification of the prone position  Hips over center break between body and leg sections of operating table  Chest rolls employed  Arms on arm boards; elbows flexed; palms down  Head to the side on donut  Pillow under ankles  Safety belt below the knees

64. Kraske (continued)  Leg section lowered; entire table tilted head downward so hips are elevated above body  Return patient to level position slowly  Remove safety belt when moving table parts  Venous pooling occurs cephalad and caudad  Kraske position not tolerated well by patients  Procedures  Rectal  Pilonidal sinus

65. Knee-Chest Position  Modification of the prone position  Foot extension  Table flexed at center break  Leg section at right angle to operating table  Patient kneels on lower section  Knees are flexed at right angle to body  Head turned to side; placed on donut

66. Knee-Chest (continued)  Arms placed on pillow near head with elbows flexed  Safety belt above the knees or tape used  Pillows placed on foot board and taped into place  Procedures  Spine

67. Lateral Position  Anesthesia administered with the patient in the supine position, then repositioned onto the non-operative side  Turned by no fewer than 4 people  As patient is turned, patient’s back drawn to edge of operating table  Arms placed on overhead armboard; lower arm palm up; upper arm slightly flexed with palm down

68. Lateral (continued)  Lower leg flexed at knee  Upper leg straight  Large pillow placed lengthwise between legs to prevent pressure on peroneal nerve  Safety belt or wide tape placed over hip to provide stability  BP taken from lower arm  Small roll under axilla to relieve pressure

69. Lateral (continued)  Shoulders in alignment  Head in cervical alignment  Supported by pillow between shoulder and neck to prevent stretching the neck, brachial plexus, aid in maintaining patent airway  Procedures  Thorax  Kidney  Retroperitoneal space

70. Kidney Position  Modification of lateral position with flank region over kidney elevator  Short kidney rest attached to elevator at patient’s back  Longer rest placed on front below level of iliac crest to prevent pressure on abdominal organs  Table slightly flexed  Kidney elevator raised to increase space between lower ribs and iliac crest

71. Positions  Safety strap or wide tape placed after table flexed and elevator raised  Entire table tilted head downward until surgical area is horizontal  All lateral positions, shoulder, hip, knee, ankle in alignment  Before closure, table is flattened to allow better approximation of tissues  Procedures  Kidney