1. Positioning in anaesthesia
Dr. S. Parthasarathy
MD., DA., DNB, MD (Acu),
Dip. Diab. DCA, Dip. Software statistics
PhD (physio)

2. Goals Avoid pressure on the chest cavity To maintain circulation
To prevent nerve damage
To maintain patient’s airway
To provide adequate exposure of the operative site
To provide comfort and safety to the patient

3. Positions – common
Patient is not aware of the damage and he cant tell that my eye is getting compressed
supine,
lithotomy,
sitting,
head-down,
prone,
lateral decubitus

4. Supine

5. Supine We spent most of our life like this Be careful
patients with morbid obesity,
mediastinal masses,
poor cardiac function and
term parturients prone to aortocaval compression .

6. Supine

7. Step off effect

8. Supine
prolonged contact of the back of the head may result in alopecia
ulnar neuropathy is the most common- males
0.25 % may be delayed upto 3 days
Brachial plexus, femoral cutaneous nerves are next common.
Brachial or ulnar ??

9. Head rotation
putting brachial
plexus under
traction
Excess abduction of
upper limb
Forearm pronation
putting pressure on
ulnar nerve in ulnar
groove

10. CVS in supine MAP, heart rate (HR),venous return rises
peripheral vascular resistance decrease
cardiac output and stroke volume increase.
Offset anaesthetic action

11. RS cephalad movement of the abdominal contents.
The main complications are airway obstruction and decreased tidal volumes
The resulting reduction in functional residual capacity (FRC) is detrimental to gas exchange
increase in ventilation–perfusion mismatching and decrease in pulmonary compliance.

12. loss of the natural lumbar lordosis
associated with postoperative low back pain.
The occiput, sacrum and heel are at risk of developing pressure sores

13. Supine with pads and arms by the side with pads

14. Lawn Chair Position

15. Lawn Chair Position modification of the standard supine position
the lower and upper halves of the body are slightly elevated in relationship to the hips
Better venous drainage , better muscle relaxation

16. beach chair position

17. beach chair position
beach chair position is associated with the risk for cerebral underperfusion.
Blood pressure must be maintained at a level that guarantees a perfusion pressure of 60 to 70 mm Hg measured at the level of the foramen magnum

18. Trendelenburg

19. Trendelenburg
Central blood volume increase by 1 litre. swelling of the face, conjunctiva, larynx, and tongue ?? postoperative upper airway obstruction.
The cephalic movement of abdominal viscera against the diaphragm also decreases functional residual capacity and pulmonary compliance.

20. Effects of Trendelenberg’ s position
↑ CVP
↑ ICP
↑ IOP
↑ myocardial work
↑ pulmonary venous pressure
↓ pulmonary compliance
↓ FRC
Swelling of face, eyelids, conjunctiva & tongue
observed in long surgeries
18 September 2018

21. Trendelenburg The stomach also lies above the glottis
Visualize the larynx before extubation.

22. Reverse trendelenburg

23. Reverse Trendelenburg position(head-up tilt)
to facilitate upper abdominal surgery by shifting the abdominal contents caudad.
This position is popular because of the growing number of laparoscopic surgeries.
slipping on the table,
monitoring of arterial blood pressure.

24. Reverse Trendelenburg position
hypotension and increased risk of venous air embolism (VAE).
the position of the head above the heart reduces perfusion pressure to the brain

25. Lithotomy This position is most often used for
genitourinary, gynecologic, and colorectal
Procedures.
Hips flexed 100 deg deg. abduction at the hips
. Knees 90 approx 30 deg

26. ARMS – side and tucked in

27. Martin and Warner have proposed a standardized classification
low,
standard,
high,
hemi,
exaggerated,
tilted
Martin JT, Warner MA (Eds): Positioning in Anesthesia and Surgery, 3rd edition. Philadelphia, WB Saunders, 1997

28. Low and standard

29. High and hemi

30. Exaggerated and tilted

31. Various lower limb fixations

32. Lithotomy
coordinated positioning of the lower extremities by two assistants to avoid torsion of the lumbar spine.
Both legs should be raised together, flexing the hips and knees simultaneously.
Slow removal
Hands beware

33. lithotomy from the supine position
Unanticipated stimulation of the carina with bronchospasm or endobronchial intubation may result.
In the lithotomy position, calf compression is almost inevitable and this predisposes to venous thrombo embolism and compartment syndrome ( surgery > 5 hours)

34. MAP at various levels

35. Lithotomy
Lower extremity compartment syndrome is a rare complication associated with the lithotomy position.
perfusion to an extremity is inadequate, resulting in ischemia, edema
extensive rhabdomyolysis from increased tissue pressure within a fascial compartment

36. Nerve injuries
injury to the common peroneal nerve was the most common lower extremity motor neuropathy, representing 78% of nerve injuries.
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.

37. Nerve injuries in lithotomy

38. Exaggerated Lithotomy
Extreme flexion of the hip joints can cause
neural damage by stretch (sciatic and obturator nerves)
direct pressure (compression of the femoral nerve as it is passes under the inguinal ligament)

39. Hemodynamics and RS
preload increases, transient increase in cardiac output
Cerebral venous and intracranial pressure in otherwise healthy patients.
causes the abdominal viscera to displace the diaphragm cephalad, reducing lung compliance and potentially resulting in a decreased tidal volume

40. The frog-leg position hips and knees are flexed
hips are externally rotated with the soles of the feet facing each other,
allows access to the perineum, medial thighs, genitalia, and rectum.
Care must be taken to minimize stress and postoperative pain in the hips and prevent dislocation by supporting the knees appropriately

41. The prone or ventral decubitus position
used primarily for surgical access to the posterior fossa of the skull,
the posterior spine,
the buttocks and
perirectal area,
and the lower
extremities.

42. Prone position Minimal neck flexion anterior flexion, abducted and
nipple
genital
Minimal neck
flexion
anterior flexion, abducted and
externally rotated
No pressure in
axilla
Abdomen
free
Face in
soft headring
with no
pressure
on eyes
and nose
Elbow
padded

43. Abdomen pressure in prone
inferior vena caval compression,
reduced venous return and subsequent poor cardiac output.
Associated pulmonary problems are caused by an increase in transdiaphragmatic pressure leading to reduced thoracic compliance.

44. RS – better
An increase in FRC, changes in diaphragmatic excursions and improved ventilation–perfusion matching can significantly improve oxygenation in the prone position.
for treatment of refractory hypoxaemia and in early ARDS
70–80% of patients turned prone initially benefit from improved oxygenation

45. Prone position Complete obstruction of the contralateral
vertebral blood flow with rotation of the head >80
Beware in old CVAs
‘Concorde’ position with the neck flexed and the chin approximately one finger-breadth from the sternum

46. Prone position with Wilson frame

47. Mirror type

48. Horse shoe adapter , may field head pins

49. Relton-Hall frame

50. Wilson laminectomy frame

51. Park bench position- 3 quarter prone

52. The prone jackknife position

53. The prone jackknife position
is often used for anorectal surgery.
is first placed prone, and all pressure
points are padded.
The patient is situated on the table such that when the table is anteflexed the apex of the
inverted “V” is at the patient’s inguinal
region.

54. Knee chest position sigmoidoscopies or lumbar laminectomies
Severe hypotension is seen due to pooling of blood in the legs

55. The Andrews kneeling frame with Wiltse's thoracic jack in use

56. Watson jones ortho table

57. Watson jones ortho table
Brachial plexus injury
Due to > than 90* extension of the upper limb
Lower extremity compartment syndrome
Due to long surgeries & compression
Pudendal nerve injury
Due to pressure of the perineal post

58. This table also !!

59. The lateral decubitus position
surgery involving the thorax,
retroperitoneal structures,
hip.

60. The lateral decubitus position

61. The lateral decubitus position

62. The lateral decubitus position

63. The lateral decubitus position
V/Q mismatch
Maximal ocular complications
BP check up especially in kidney position
Nerve injuries

64. Sitting Venous air embolism Not frequently used Craniotomy
Venous return decrease and cardiac output decrease
HR no change
Venous air embolism

65. Sitting

66. Sitting
overall increase in ventilation with increased VC and FRC.

67. Pressure points

68. Nerve injuries- overall
ulnar neuropathy has been found in as many as 26% of patients undergoing open-heart surgery
lower extremity neuropathy occurred in 1.5% of patients in the lithotomy position.
The incidence of ulnar neuropathy is estimated at 0.46% after noncardiac surgery

69. Overall mechanism of nerve injuries
(i) stretch,
(ii) compression,
(iii) generalized ischaemia,
(iv) metabolic derangement.

70. all predispose to perioperative nerve injury
Peripheral vascular disease,
diabetes,
hereditary neuropathy, and
anatomic variation (eg, cervical rib),

71. Brachial plexus

72. Ulnar nerve in flexion

73. Suprascapular nerve stretch

75. Wedge in pregnant
A rare complication of this positioning is sciatic neuropathy, suggesting that time in this position should be minimized
Early intervention within 48 hours with EMG studies
no significant difference in the incidence of ulnar neuropathy in patients undergoing general anaesthesia, regional anaesthesia or sedation.

76. Double crush phenomenon

77. Effects of Positioning - Obese Patients
Lateral:
Well tolerated
Correct sizing and placement of axillary roll is important
Ensure that pendulous abdomen does not hang over side of OR bed
Head-Up: (Reverse Trendelenburg/Semi-recumbent)
Most safe
Weight of abdominal contents unloaded from diaphragm
Use of well-padded footboard to prevent sliding

78. Ocular injuries
The frequency of eye injury during anaesthesia and surgery is very low (<0.1% of anaesthetics),
As little as 10 min
Corneal abrasions, periorbital,and conjunctival edema, ocular hemorrhage,
vitreous loss, retinal detachment,
central retinal artery occlusion,
ischemic optic neuropathy

79. Causes Patient movement, chemical irritation from prep solutions,
direct trauma from face mask,
pressure from the laryngoscopic blade,
pressure effects on the globe from lateral
and prone positioning, (duration )
intraoperative hypotension, and anemia

80. Contributing patient comorbid conditions
hypertension, diabetes,
obesity, smoking history, hypercholesterolemia,
alcohol abuse, atherosclerosis,
anemia, Graves disease,
and renal transplantation
Tape ok !!! Ointment ??

81. Don’t Forget: Good positioning starts with an assessment
Prevent surgical team members from leaning
Arm board pads should be level with table pads
Cushioning of all pressure points is a priority -
Procedures longer than 2 ½ to 3 ??
During a longer procedure, shifting the patient, adjusting the table, or adding/removing a positioning device
assess extremities at regular intervals for signs of circulatory compromise
Documentation of the positioning process- accurate and complete

82. Summary Change – check all Cardiac Respiratory Nerve injuries
Pressure sores
Visual loss
Follow up for some days

83. Comfortable position

84. Uncomfortable position

85. Uncomfortable position but happy

86. Thank you all