1. PATIENTS AT RISK THE ART & SCIENCE OF PATIENT POSITIONING™
A Patient Positioning injury is any dysfunction, discomfort, or injury not related to the surgical site, they are for the most part PREVENTABLE
Presented by: Clare Tager, BSE, MFA,
Designed by: Candi Forney,

9. O.R. Nurses frequently do not hear....

10. “Peripheral nerve injuries are a significant source of anesthesia-related liability claims….The signs of denervation resulting from acute injury appear 18 to 21 days after the event and are limited to a specific nerve distribution. Recovery from peripheral nerve injury is often slow, taking 3 to 12 months and during this time the patient may experience pain and disability.” ~Basics of Anesthesia

11. “Freedom from injury related to positioning is one of a number of expected outcomes of the surgical experience.” ~ AORN Standards and Practices

12. “The perioperative nurse should view positioning as a specialized piece of knowledge that when applied can make a distinct difference in patient outcomes. The practice of patient positioning is rational and logical. Positioning is grounded in basic knowledge of anatomy and physiology. The perioperative nurse approaches positioning with a sense of urgency and intense thought.” -~Alexander’s Care of the Patient in Surgery

13. The sequelae of improper positioning may be temporarily discomforting, permanently disabling, or may terminate in the death of the patient. Operative position has been the direct cause of injuries to delicate nerves, skeletal and supporting structures and other organs and tissues; the sporadic reporting of such accidents in the medical literature makes one suspect that many more accidents occur, but fail to be reported. There are no reliable statistical data to reveal the incidence of complications related to body position during surgery. ~Dr. John Lincoln, Director of Anesthesia, Maine Medical Center, Complications related to Body Positions During Surgery

14. Factors Leading to Injury
Faulty Positioning of the Patient
Undue Haste
Failure to insist on an adequate number of personnel before a position change
Equal=potential for injury to patient (and staff!!)
Post Op Backache one of the most common complications!

15. Back Pain

16. Nerves at Risk

17. Brachial Plexus

18. Ulnar Nerve

19. Femoral Nerve
Example: Hyper-flexion can damage this nerve, i.e. High lithotomy, when hips are flexed too far back or low lithotomy when leg is stretched lower than the plane the abdomen.

20. Saphenous Nerve
Saphenous Nerve is a branch of the femoral that supplies cutaneous branches to the inner aspect of the leg and foot
(Also distal, sural and plantar nerves)
Ankle straps of candy canes can put pressure on these which could result in neuropathies of the foot.

21. Obturator Nerve
Injury can occur as a result of over-abduction of legs in lithotomy.
Patient loses sensation on inner aspect of thigh (can’t bring thighs together – gait and balance affected.
Leg has to swing out before making contact with surface.

22. Sciatic Nerve Runs behind the length of the leg down into the foot.
Exaggerated flexion can stretch it. So hyper abduction or hyperextension can damage this nerve.
Think of a licorice stick – stretch it. Now try and get it back to it’s original size and configuration. With enough alternating hot and cold, perhaps over time…but very painful.
Severe Pain, Foot drop, loss of Knee flexion can result. Flexing legs less than 45 degrees from abdomen is a problem

23. Peroneal Nerve Branch of the Sciatic Nerve
Comes out of the outer aspect of the knee and affects motor properties in the anterior and lower leg
The sensation of our legs going to sleep is the result of pressure placed on our peroneal nerve
It is one of the most frequently damaged by being compressed against stirrup bar and can cause foot drop, loss of dorsal extension of the toes, inability to evert the foot and loss of sensation below the knee

24. PRESSURE/ ORAPU O.R. ACQUIRED PRESSURE ULCERS
“Documented incidents for ORAPU - between 8.5% and 66%”
“Surgical positioning affects the risk and location of skin breakdown... adding surface layers, i.e. cloth, warming blanket on top of a pressure reducing surface negates the the effect of the pressure reduction surface and produces a higher pressure reading than would be expected... Hence negativity.”
~Sharon Aronovitch, Phd., APRN,BC, CWOCN, Intraoperatively Acquired Pressure Ulcers, 1998

25. AORN STANDARDS & PRACTICES 2008
Capillary closure Point is 32mmhg, yet research studies found foam overlays or replacement pads ( most OR bed mattresses) do not have effective pressure reduction capabilities
Standard OR Table pads (even new ones) may not reduce capillary interface pressure for all body types
Pressure readings as high as 150mmhg noted during prolonged unrelieved pressure without position change
Studies show viscoelastic overlays are effective for preventing skin changes and pressure sore formation, offering most benefit for older patient population, patients with chronic health problems, vascular disease or surgical procedures over 2 hours

26. “Pressure ulcers slow patients recovery and prolong their hospital stays, Worse, nearly 60,000 US hospital patients are estimated to die each year from complications due to hospital acquired pressure ulcers, The total annual cost for treating pressure ulcers in the US is estimated at $11 billion”
~IHI 5 Million Lives Campaign, How to Guide: Prevent Pressure Ulcers

27. Medicare Regulations
Effective October 2008, Medicare no longer reimburses for a number of hospital-acquired complications, including pressure sores. 
Aronovitch study: “Treatment of a single ulcer has been estimated to cost up to $40,000.”

28. RESOURCES SUZY SCOTT-WILLIAMS, RN, MSN, CWOCN
(901) ext 7136, VA Medical Center Memphis, TN

29. Anatomic Locations of Pressure Ulcers
Sacrum %
Heel %
Ischium (sit bone) %
Elbow %
Malleolus (ankle bone) %
Trochanter (hip bone) %
Knee %
Scapula (shoulder blade) 2.4%
Occiput (back of head) %
Amlung SR, Miller WL, Bosley LM, Adv Skin Wound Care Nov/Dec;14(6):
Amlung SR, Miller WL, Bosley LM, Adv Skin Wound Care Nov/Dec;14(6):
Occiput
Scapula
Elbow
Trochanter
Sacrum
Ischium
Knee
Malleolus
Heel
30.3% Heels

30. Perioperative Pressure Ulcer (PPrU) Defined
A Perioperative pressure ulcer is any pressure related tissue injury that presents i.e. non-blanchable erythema, purple discoloration or blistering within hrs post-operatively and is associated with the surgical position. ~Scott Williams (2005)

31. Perioperative Pressure Ulcer Prevention Program (PPUP)
Assessment
Perioperative Nursing Care Plan
Universal Pressure Precautions
Product Specification
Staff Education & Awareness
Evidence-based Best Practices
Nursing Specialty Collaboration
Quality Improvement

32. Scott Triggers™ Assess pre-op for ALL Four Triggers Age over 62
Albumin < 3.5
ASA Score 3 or greater
Surgery > 3 hours (time in/out of OR)
Consider cardiac, vascular, trauma, transplants, and bariatric procedures
2 or more triggers=HIGH RISK SURGICAL PT
ASA
& TIME
ALB
AGE

33. Risks Involving Morbidly Obese and Bariatric Patients
“Patients who are 100% over normal weight can have as much as a 40-50% increase in the mechanical work of breathing.” ~Alexander’s Care of the Patient in Surgery

34. Morbidly Obese Patients Positioning Concerns
AORN Standards and Practices
Bed must articulate and support 800 to 1000 pounds
Mattresses should not ' bottom out"
Width of legs determines whether lower legs remain on bed or require stirrups. Check stirrup weight limit. Consider table width extenders
Padded Sleds may be used to contain patients arms at side of body as long as no excessive pressure on arms
Extra wide extra long safety straps ( Sheets not a good substitute) One safety strap across thighs, one over lower legs
In Supine, a roll or wedge under right flank to relieve compression of vena cava

35. Morbidly Obese Patients Positioning Concerns
AORN Standards and Practices
In Prone, support for the upper chest and pelvis reduces pressure on diaphragm and inferior vena cava
Trendelenburg should be avoided, as added weight of abdominal contents press against diaphragm, respiratory compromise, increased blood flow from lower extremities causes vascular congestion
Lithotomy should be avoided if possible due to weight of patients thighs pressing on abdomen and raising intra- abdominal pressure, risk of circulatory complications
Lateral position may be preferred instead of prone but nursing awareness that shifts in weight can in itself increase risk of falling

36. Lithotomy

37. The Time Factor
“A recent study showed that patients in the lithotomy position sustained few injuries during the first hour of surgery, but each additional hour posed a 100-fold increase in the risk for neuropathy.” ~Dr. Mark Warner, Mayo Clinic, Department Anesthesia

38. Lithotomy
"Hyperextension can sometimes occur intraoperatively when the patient is draped and you cannot see the leg. The resulting injury is foot drop as well as loss of knee flexion.“ ~Dr. John Martin, Introduction to Positioning

39. Lithotomy Risks Hyperflexion = < 45 degrees from the abdomen
Hyperextension = No flexion in knee or leg lower than the plane of the abdomen in low lithotomy
Lithotomy Risks

40. “If arms are to be tucked, the sheet needs to be under the patient and not underneath the mattress. When sheet is underneath the mattress, arms can more easily drop over the edge of the bed and become compressed against metal sidebars or mattress. Obese patients are at risk here if patient is too large for the OR bed. Such compression could injure ulnar, radial, or medial nerves”.
~Alexander’s Care of the Patient in Surgery

41. Stirrups

42. ~Dr. John Martin, Positioning in Anesthesia and Surgery
The first consideration in patient positioning is to...
FIT THE EQUIPMENT TO THE PATIENT, NOT THE PATIENT TO THE EQUIPMENT
~Dr. John Martin, Positioning in Anesthesia and Surgery

43. Crutch Stirrup
If stationary knee-padded stirrups are used, excessive pressure may be placed on the popliteal space.
~Alexander's Care of the Patient in Surgery

44. Boot Stirrup Place sockets at hips
Extend the legs if going into high lithotomy
Avoid over-flexion less than 45 degrees from the abdomen
Avoid frog-legging
Line up toe, knee, opposite shoulder

46. Caution! Incorrect Positioning

47. Candy Canes
“What you do in the few minutes you have to position a patient for surgery can have lasting consequences. Candy Cane leg holders that wrap around the head of the fibula can compress the leg’s peroneal nerve. Excessively abducted hips increase the strain on the obturator nerve and can cause pain and adductor muscle dysfunction. Hip flexion increases pressure on the femoral and lateral femoral cutaneous nerves and can cause painful paresthesias.” ~Outpatient Surgery, 6 Patient Positioning Pointers, Nathan Hall, Editor, April 2008

48. Placement of Patients Buttocks on Edge of OR Table
“The Patients Buttocks should not extend over the break of the bed to prevent pressure areas and to decrease lower back strain” ~AORN Positioning Module
Note also, Peroneal Nerve area being compressed against the post. ~Dr. John Martin

49. Uncontrolled Abduction
“Uncontrolled abduction of the thigh can manifest in post-operative back-ache and stretching in the groin area can manifest as an Obturator nerve injury.”
~AORN Positioning Module

50. Address at ACOG 2003
“Avoid candy cane stirrups! I know plenty of people still use these things, but many of us are getting away from this practice. They basically just hang your leg dangling there which is not ideal for making sure the patient’s leg is safe.” He encouraged his audience of fellow Gynecologists to use boot stirrups and to do the positioning themselves adding, “make sure you feel comfortable with the positioning because you’re the one who’s going to be in court if there is a problem.” ~Dr. William Hurd, Professor of Gynecology, Wright State University, Dayton, Ohio, ACOG

51. AORN Standards 2009 Lithotomy
Stirrups placed at even height
Patients buttocks should be even with the lower break of the procedure bed and positioned in a manner that securely supports the sacrum on the bed surface
Legs moved slowly and simultaneously into holders to prevent lumbosacral strain
To maintain hemodynamic status, legs slowly returned to bed
Arms extended less than 90 degree

52. AORN Standards 2009 Lithotomy
Arms tucked only if surgically necessary with elbows padded and palms facing in toward body
Support should be provided over the largest surface area of the leg positioner
Legs should not rest against stirrup posts
Scrubbed personnel should not lean against patients thighs
Patient should be in the lithotomy position for the shortest time possible

53. 1885 TRENDELENBURG

54. Staff Seeking Solutions
" It is definitely an uncomfortable position as the blood pools in your head. Even the surgeon commented ‘We do this to our patients?’ If you have never been positioned Trendelenburg, I suggest you try it. In our peri-op classes we included many positions for our new staff members to practice and to experience but not Trendelenburg; now it will be on the list." ~Claudia Campese RN CNOR Nurse Educator, New Hanover Regional Medical Center, Wilmington NC

55. Trendelenburg Risks
“Any variation of Trendelenburg’s position should be maintained only as long as necessary” - Alexander’s Care of the Patient in Surgery
Excessive pressure on clavicle = compression on B-Plexus
Morrell Closed Claims: B-Plexus injury results from shoulder braces and Trendelenburg
Patients with history of heart failure especially at risk
Gravitational blood flow away from surgical field masks blood loss.
Cerebral blood flow may fall as pressure rises
Trendelenburg can equal visual loss related to decrease venous return from head
~ AORN Standards & Practices 2009

56. Alexander’s Trendelenburg
CONSIDERATIONS
Sliding in Trendelenburg: Issues
Steeper degrees of Trendelenburg with new OR tables
Robotics

57. Deep Venous Thrombosis
“Steep Trendelenburg position with acute flexion of the knees may cause kinking of a diseased popliteal artery, with damage resulting in thrombosis, gangrene, and requiring amputation.” ~Dr. John Lincoln

58. Alexander’s Prone

59. Spinal Frame

60. Spinal Frame Positioning Issues
Morbidly Obese/Bariatric Patients

61. Spine Frame Positioning Issues
Imaging
Visual Access
Decompressed Abdomen
Pressure Management
Skin Sheer & Maceration
Face
Large Patients
Pediatrics
Brachial Plexus
Breasts

62. The Prone Positioning of Patients on Operating Room Equipment: Intraoperative Complications ~Helen Manson, Professor of Anesthesia, UK
Cardiopulmonary: Pressure on abdomen compresses inferior vena cava and femoral veins,…. Support surfaces that minimize intraabdominal pressure are essential
Respiratory: High airway pressures and large tidal volumes need to ventilate a patient improperly positioned can have severe side effects. The patient who is supported with the abdomen FREE FROM PRESSURE will have improved ventilation and oxygenation
Neurological: Careful positioning of the neck and head support in a neutral postion are ESSENTIAL to prevent neurological injury while prone. Use of Chest Rolls led to increased venous pressure which .. decreased the perfusion pressure in the spinal cord, causing Ischemia. CASE: Pt had fatal ischemic stroke after being positioned prone with head rotated during spine surgery
Case: Postoperative Paraplegia due to cervical spine injury attributed to neck positioning during prone spine surgery

63. The Prone Positioning of Patients on Operating Room Equipment: Intraoperative Complications ~Helen Manson, Professor of Anesthesia, UK
Patient support devices that minimize abdominal compression and maintain neck and body in NEUTRAL position can help prevent these neurological complications
Nerve: Peripheral nerve injury one of the most frequent causes of morbidity Compression of lateral femoral cutaneous nerve a common complication. Support devices that minimize pressure are key
Skin: Prone patients at high risk for pressure ulcer development Iliac bony prominences common area for pressure ulcers . The prolonged nature of these spinal procedures increase likelihood of shearing and pressure injury
Pressure: Prone positioning may inadvertently damage breast tissue, resulting in chest wall pain, breast tenderness or bleeding of nipples Longitudinal positioning frames or rolls can damage breast tissue by direct compression, Rupturing of implants also noted
Ocular: Compared with Supine and lateral positioning, there is a ten fold increase in eye injury associated with surgery while prone. In addition to Corneal abrasions, POVL Postoperative visual loss is associated with spinal surgery. 67% of all cases of POVL registered on ASA Registry occurred after spine surgery. ASA has a task force set up on post operative blindness due to prone positioining

64. Nerve damage from Coronary Artery Bypass Surgery can Affect Arm Functioning ~Dr. Joseph Episcopio, Senior Attending Physician in Internal Medicine, Lehigh Valley, PA
One seldom discussed complication is injury to the brachial plexus nerve which should be considered when the patient complains of acute onset of shoulder pain, weakness and/or paralysis following the surgical procedure.
Brachial plexus injury
Patient experience intense pain and discomfort
Delay in return to employment(uncompensated)
Possible permanent disability.
Emergence of Emotional involvement
Depression
Anxiety

65. Mr. Thompson, 62 year retired pharmacist was admitted to Methodist Medical in Memphis, Tennessee in 1982 for a coronary bypass.....

66. This gentleman was my Dad...
Pain
Discomfort
Emotional Involvment
Depression
Anxiety
This gentleman was my Dad...

67. Patient Advocacy… You are the voice for the voiceless